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http://www.archive.org/details/practicalsurgeryOOsenn 


Practical  Surgery 


For  the  General  Practitioner 


BY 

NICHOLAS  SENN,  M.D.,  Ph.D.,  LL.D. 

Professor  of  Surgery,   Rush  Medical  College,   in  affiliation  with  the   University  of  Chicago ; 

Attending    Surgeon  to  the    Presbyterian    Hospital  5    Surgeon-in-Chief,    St.    Joseph's 

Hospital ;    Professional    Lecturer    on    Military    Surgerv,     University    of 

Chicago  5    Surgeon-General   of  the   State   of   Illinois. 


WM  65o  Illustrations,  many  of  them  in  Colors 


PHILADKLPHIA    AND   LONDON 

W.   B.  SAUNDKRS  6c  COMPANY 

1 90 1 


Copyright,  1901,  by  W.  B.  Saunders  &  Company 


Registered  at  Stationers'  Hall,  London,  England 


Se5Z 


PRESS  OF 

W.  e.  SAUNDERS  &   COMPANY 

PHILADELPHIA 


THIS  BOOK 

IS    RESPECTFULLY    DEDICATED    BY    THE    AUTHOR 

TO 

LEVI    C.    LANE 

Professor  of  Surgery  in  the  Cooper  Medical  College,  San  Francisco 

^         The  erudite  scholar,  the  popular  and  successful  teacher,  the  eminent  author,  and 
the  pioneer  of  modern  surgery  on  the  Pacific  slope 

AND   TO 

The  General  Practitioners  of  this  Country 

for  whose  interests  and  instruction  the 
work  has  been  written 


N 


PREFACE. 


This  book  is  not  intended  to  cover  the  whole  field  of  surgery.  Its 
contents  are  devoted  to  those  sections  of  surgery  that  are  of  especial 
interest  to  the  general  practitioner.  Injuries  and  acute  surgical  diseases 
usually  first  come  under  the  treatment  of  the  general  practitioner,  and  as 
the  fate  of  the  patient  often  depends  on  the  efficiency  of  the  first  aid 
rendered,  it  is  evident  that  the  attending  physician  should  be  thoroughly 
trained  and  competent  in  everything  that  pertains  to  emergency  work. 
The  average  medical  student  is  more  interested  in  surgery  than  in 
medicine,  and  the  surgical  training  he  receives  ought  to  qualify  him 
to  treat  all  kinds  of  emergency  cases  with  credit  to  himself  and  with 
benefit  to  his  patients.  Neglect  and  mistakes  made  in  this  department 
of  professional  work  are  often  difficult  to  balance  and  correct  later. 
The  general  practitioner  should  never  lose  interest  in  the  surgical  work 
that  naturally  belongs  to  him,  and  should  endeavor  to  keep  abreast  of 
the  advances  and  improvements  that  are  constantly  being  made.  His 
surgical  field,  although  limited,  is  yet  a  very  important  one,  and  fraught 
with  great  responsibilities.  He  must  be  familiar  with  surgical  diagnosis, 
and  must  acquire  sufficient  surgical  technic  to  enable  him  to  act  wisely 
and  safely  in  all  surgical  cases  in  which  immediate  action  is  an  absolute 
necessity  to  the  preservation  of  life  or  to  the  protection  of  the  patient 
against  remote  disastrous  complications. 

The  physician  who  is  qualified  to  practise  emergency  surgery  should 
never  forget  that  he  must  keep  himself  in  readiness  to  respond  to  an 
urgent  message,  and  in  doing  so  he  adopts  and  follows  the  motto  of 
this  book  :    "  Semper  paratus.  " 

Familiar  with  the  needs  of  the  general  practitioner  as  a  surgeon,  the 
author  has  aimed  to  simplify  and  lighten  his  often  trying  work  by  limiting 
the  scope  of  the  book  to  a  discussion  of  only  those  subjects  that  come 
within  the  legitimate  sphere  of  the  daily  routine  work  of  every  practising 
physician.  He  has  taken  the  liberty  to  quote  freely  from  his  own  ex- 
perimental and  literary  productions  on  all  occasions  where  it  appeared 
to  him  advisable  to  do  so.  Some  of  the  subjects  have  been  treated  at 
great  length,  for  which  no  other  apology  is  made  than  their  great  clinical 
and  surgical  importance  to  the  general  practitioner.  Intestinal  surgery  is 
given  a  prominent  jjlace,  and  the  consideration  of  this  subject  is  based 
on  the  ojjcrative  experience  of  the  author  for  a  ([uarter  of  a  century. 

9 


lO  PREFACE. 

The  text  is  profusely  illustrated,  with  the  hope  that  this  feature  will 
add  to  the  value  of  the  book  as  a  guide  in  practice.  Sixty-four  of  the 
original  illustrations,  a  number  of  them  colored,  were  made  by  Mr.  C.  F. 
W.  Eberhard,  who  is  entitled  to  much  credit  for  his  excellent  work. 
Many  of  the  illustrations  are  original,  and  others  have  been  selected  from 
sources  not  readily  accessible  to  the  average  practitioner. 

As  books  of  reference  utilized  in  the  preparation  of  this  work,  the 
following  deserve  special  mention :  von  Esmarch,  ' '  Handbuch  der 
Kriegschirurgischen  Technik  ' '  ;  von  Esmarch  and  Kowalzig,  * '  Chir- 
urgische  Technik";  von  Bruns,  ''Die  Lehre  von  den  Knochen- 
briichen  ";  Hoffa,  "  Lehrbuch  der  Fracturen  und  Luxationen." 

The  material  for  the  sections  on  Military  Surgery  and  Gunshot 
Wounds  was  gathered  from  the  author's  observations  and  experiences 
during  the  Greco-Turkish  and  Spanish-American  wars. 

Much  credit  is  due  to  the  publishers  for  their  liberality  in  illus- 
trating the  book  so  profusely,  and  to  Dr.  Charles  Adams  for  careful 
proofreading. 


CONTENTS. 


CHAPTER  I.  PAGE 

Emergency  and  Military  Surgery 17 

CHAPTER  n. 
Traumatic  Shock 28 

CHAPTER  HI. 

General  Anesthesia 4° 

Chloroform  Anesthesia,  44 — Preparations  for  Anesthesia,  45 — 
Accidents  during  Narcosis,  50 — Artificial  Respiration,  53 — Ether 
Anesthesia,  56 — Local  Anesthesia,  58 — Schleich's  Solution,  61 — 
Eucain,  61. 

CHAPTER    IV. 

Prophylactic   Hemostasis 62 

Elevation,  63 — Elastic  Constriction,  64 — Special  Localities  for 
Elastic  Constriction  as  a  Prophylactic  Hemostatic:  Hip-joint,  73 — 
Shoulder-joint,  81 — Head,  81 — Manual  Compression  of  the 
Aorta,  82 — Digital  Compression,  84 — Preliminary  Ligation  of  Ar- 
teries in  their  Continuity,  85 — Temporary  Liga'tion  of  Arteries, 
86 — Galvanocautery  and.  Thermocautery,  88 — Angiotripsy,  88 — 
Spanish  Windlass,   89 — Ecraseur,  89. 

CHAPTER    V. 

Treatment  of  Hemorrhage 9° 

Classification,  91 — Spontaneous  Arrest  of  Hemorrhage,  94 — 
Symptoms  and  Diagnosis,  95— Treatment,  96 — Vessel  Suture, 
122 — Arterial  Invagination,  126 — Torsion,  127 — Forcipressure, 
128 — Actual  Cautery,  128 — Hot  Water,  129 — Steam,  130 — Cold, 
131 — Acupressure,  131 — Aseptic  Tamponade,  131 — Wound  Su- 
ture, 132 — Electricity,  133 — Styptics,  133 — Hemorrhage  from 
Bone,  134 — General  Treatment,  134. 

CHAPTER    VI. 

Wounds     •       ^42 

Incised  Wounds,  145 — Lacerated  Wounds,  147 — Contused 
Wounds,  148 — Stab  Wounds,  150 — Punctured  Wounds,  150 — Gun- 
shot Wounds,  152 — Poisoned  Wounds,  152 — Repair  of  Wounds, 
153 — Primary  Intention,  154 — Secondary  Intention,  156 — Wound 
Infection,  157 — Prevention  of  Infection,  164— Operating  Room, 
164 — Hand  Disinfection,  169 — Disinfection  of  Field  of  Injury, 
172 — Sterilization  of  Instruments,  174 — Aseptic  and  Antise])tic 
Dressing  Material,  180 — Antipyogenic  Agents,  184 — Antiseptics, 
186 — Acetate  of  Aluminum,  187 — Alcohol,  188— Boric  Acid,  188— 
Bromin,  188— Camphor,  189— Carbolic  Acid,  189— Chloral  Hy- 
drate, 190— Chlorid  of  Lime,  190— Chlorid  of  Sodium,  190— Chlo- 
ridofZinc,  190— Chromic  Acid,  191— Corrosive  Sublimate,  191  — 
Creasotc,  192— Crcolin,  192— Formic  Aldchyd,  192— Hydrogen 
Peroxid,  194— lodin,  194— Iodoform,  194— Juniper.  196— Lysol, 
i()6 — Peruvian  Balsam,  196— Potassium  Permanganate.  iQ?— 
Resorcin,  197— Salicvlic  Acid,  197— Salol,  197— Sulphurous  Acid, 
197 — Thymol,  197 — Tinctura  Benzoini  C^mposita,  i<)S  Turpen- 
tine, 198— Antiseptic  Solutions,  198— Carbf)lic  Acid  Solution,  201 

II 


12  CONTENTS. 

PAGE 

— Bichloridof  Mercury  Solution,  201 — Acetate  of  Aluminum  Solu- 
tion, 202 — Thiersch's  Solution,  202 — Boric  Acid  Solution,  202 — 
Chlorid  of  Zinc  Solution,  203 — Normal  Salt  Solution,  203 — Aqua 
Binelli,  203 — Permanganate  of  Potash  Solution,  203 — Antiseptic 
Powders,  203 — lodoform-boric  Powder,  204 — Borosalicylic 
Powder,  204 — Antiseptic  Salves,  204 — Antiseptic  Pomade,  204 — 
Borosalicylic  Ointment,  204 — Lister's  Boric  Acid  Ointment,  204 — 
Chloral  Hydrate  Ointment,  204 — Unguentum  Crede,  205 — The 
Mechanical  Treatment  of  Wounds,  205 — Position,  206 — Suturing, 
206 — Fixation  Dressings,  213 — Compression,  214 — Drainage,  214. 

CHAPTER  Vn. 

Gunshot  Wounds 218 

Diagnosis,  220 — Prognosis,  224 — -Treatment,  229 — First-aid  Pack- 
age in  Military  Surgery,  231 — Arrest  of  Hemorrhage  on  the  Field, 
244 — Permanent  Hemostasis,  249 — Shock,  252 — Primary  Dress- 
ing of  Wound,  252 — Immobilization  of  Injured  Joints  and  Frac- 
tured Limbs,  253 — Transportation  of  Sick  and  Wounded,  253 — 
The  Surgeon's  Work  at  the  Field-hospital,  254 — Craniectomy, 
254 — Laparotomy,  254 — Amputation,  254 — Resection,  255 — 
Wounds  of  the  Skull,  255 — Trephining  for  Traumatic  Abscess  of 
the  Brain,  256 — Treatment,  259 — Wounds  of  the  Neck,  259 — 
Wounds  of  the  Chest,  26 1 — Wounds  of  the  Abdomen,  273 — Symp- 
toms, 276 — Diagnosis,  277 — Treatment,  278 — After-treatment, 
285 — Wounds  of  the  Spine,  285 — Wounds  of  the  Nerves,  288 — 
Wounds  of  the  Arteries,  290 — Wounds  of  the  Kidneys,  291 — 
Symptoms  and  Diagnosis,  293 — Prognosis,  294 — Treatment,  295 — 
Wounds  of  the  Urinary  Bladder,  297 — Symptoms  and  Diagnosis, 
298 — Prognosis,   299. 

CHAPTER  VIII. 

Rupture  of  the  Urethra 302 

Prognosis,  304 — Treatment,  305. 

CHAPTER    IX. 

Fractures     309 

Frequency,  310 — Pathologic  or  Pseudofracture,  311 — Classifica- 
tion, 320 — Causes,  326 — Mechanism  of  the  Exciting  Causes,  327 — 
Symptoms  and  Diagnosis,  332 — The  Rdntgen  Ray  in  the  Diagno- 
sis of  Fractures,  343 — Symptoms  Following  Fractures,  344 — 
Serious  Complications  of  Simple  Fractures,  346 — Callus  Produc- 
tion, 351 — Detached  Fragments  in  the  Restoration  of  the  Contin- 
uity, 357 — Prognosis,  362 — General  Treatment,  365 — The  First 
Duties  of  the  Surgeon,  366 — Reposition  of  the  Fracture,  368 — Im- 
mobilization, 371 — Position,  372 — Remote  Consequences,  389 — 
Excessive  and  Defective  Callus  Formation,  390 — Defective  Cal- 
lus Formation,  392 — Stiffness  and  Ankylosis  of  Joints,  394 — Atro- 
phy of  the  Limbs,  396 — Thrombosis  and  Embolism,  396 — Gan- 
grene, 397 — Fat  Embolism,  398 — Hemorrhage,  398 — Central  Ner- 
vous System,  399 — Prolonged  Dorsal  Recumbency,  399 — Painful 
Callus,  400 — Paralysis,  400 — Delayed  Union  and  Pseudarthrosis, 
400— Vicious  Union,  410. 

CHAPTER   X. 

Special  Fractures     411 

Fractures  of  the  Neck  of  the  Femur,  412 — Colles'  Fracture,  475 — 
Fractures  of  the  Skull,  486 — Symptoms,  488 — Prognosis,  490 — 
Treatment,  491. 

CHAPTER  XI. 

Compound   Fractures 505 

Old  Statistics,  507 — Recent  Statistics,  508 — Etiology,  511 — Diag- 
nosis, 513 — Pathology,  514 — Prognosis,  517 — Treatment,  519 — 
Primary  Amputation,  519 — Gunshot  Fractures,  554. 


CONTENTS.  I  -. 

CHAPTER  XII.  PAGE 

Dislocations    ,-53 

Etiology  and  Mechanism.  569 — Pathology  of  Recent  Dislocations, 
571 — Symptoms,  575 — Treatment,  578 — Dislocations  of  the 
Shoulder-joint,  586 — Anterior  Dislocations,  587 — Downward  or 
Subglenoid  Dislocation,  597 — Posterior  or  Retroglenoid  Disloca- 
tion, 597 — Dislocations  of  the  Elbow-joint,  599 — Dislocation  of 
Both  Bones  of  the  Forearm,  600 — Dislocations  of  the  Ulna,  609 — 
Dislocations  of  the  Radius,  610. 

CHAPTER  XIII. 
Exploratory    Puncture,    Subcutaneous    and    Parenchymatous 
Medication,    Paracentesis,    and    Drainage    of    Suppurating 

Joints     5j^ 

•Exploratory     Puncture,     617 — Paracentesis,     620 — Drainage    of 
Suppurating  Joints,  629. 


Aseptic  Catheterization 


CHAPTER  XIV 


632 


CHAPTER  XV. 

Emergency  Operations  on  the  Air-passages 640 

Intubation  of  the  Larynx,  640 — Laryngohssure,  643 — Tracheot- 
omy, 644. 

CHAPTER  XVI. 

Empyema    6 ?  i 

Diagnosis,  653 — Surgical  Treatment,  654. 

CHAPTER  XVII. 

Peritonitis 662 

Anatomic  Classification,  663 — Pathologic  Classification,  667 — Bac- 
teriologic  Classification,  669 — CHnical  Classification,  672 — Treat- 
ment of  Septic  and  Suppurative  Peritonitis,  676 — Ectoperitonitis, 
676— -General  Septic  Peritonitis.  677 — Perforative  Peritonitis,  692 
— Circumscribed  Peritonitis,  696 — Hematogenous  Peritonitis,  700 
— Visceral  Peritonitis,  701 — Pelvic  Peritonitis,  702 — Puerperal 
Peritonitis,   703 — Subdiaphragmatic  Peritonitis,   704. 

CHAPTER  XVIII. 

Appendicitis     701; 

Size,  Location,  and  Blood  Supply  of  the  Appendix,  706 — Etiol- 
ogy, 707 — Pathology,  712 — Symptoms  and  Diagnosis,  720 — 
Treatment,  723. 

CHAPTER  XIX. 

Intestinal    Obstruction 7 :;7 

Frequency,  737 — Acute  Intestinal  Obstruction,  739 — Chronic  In- 
testinal Obstruction,  743 — Medical  Treatment,  "744 — Operative 
Treatment,  758. 

CHAPTER  XX. 

Enterostomy    761 

Enterotomy,   764. 

CHAPTER  XXI. 
Colostomy  761; 

CHAPTER  XXII. 

Abdominal  Section    770 

Preparations  for  the  Operation,  774 — Anesthesia,  77<; — Incision, 
776  —  Intra-abdominal  Examination,  777 — Operative  Treatmciitof 


14  CONTENTS. 

PAGE 

the  Obstruction,  783 — Intestinal  Anastomosis,  783 — Laparo- 
enterotomy,  797 — Enterectomy,  797 — Direct  Treatment  of  Ob- 
struction in  Strangulation  by  a  Band  or  Diverticulum,  Flexion,  or 
Adhesion  of  the  Intestines,  802 — Toilet  of  Peritoneal  Cavity, 
806 — After-treatment,  807. 

CHAPTER  XXIII. 

Enterorrhaphy  808 

Lateral  Enterorrhaphy,  818 — Circular  Enterorrhaphy,  819 — ■ 
Omental  Grafting,  821 — Murphy  Button  as  a  Substitute  for  Circu- 
lar Enterorrhaphy,  826 — Intestinal  Anastomosis  and  Lateral  Im- 
plantation, 826 — Directions  for  Preparing  Bone-plates,  828 — Je- 
juno-ileostomy,  829 — Ileocolostomy,  833 — Ileorectostomy,  839 — 
Colorectostomy,  840 — Invagination  Suture,  841. 

CHAPTER  XXIV. 
Anatomicopathologic  Forms  of  Obstruction 847 

Volvulus,  850. 

CHAPTER  XXV. 

Anatomicopathologic  Forms  of  Obstruction  (Continued) 866 

Flexion,  866 — Adhesions,  870 — Bands  and  Diverticula,  872 — In- 
ternal Hernia,  883 — Invagination,  885 — Etiology,  889 — Symp- 
toms and  Diagnosis,  893 — Pathology  of  Acute  Invagination,  894 
— Pathology  of  Chronic  Invagination,  897 — Treatment,  898 — Im- 
paction by  Foreign  Bodies,  912 — Enterolithiasis,  914 — Treatment, 
918 — Intestinal  Concretions,  920 — Parasites,  922 — Fecal  Obstruc- 
tion, 924 — Nonmalignant  Stenosis,  925 — Tumors,  961 — Benign 
Tumors,  961 — Intraperitoneal  Myofibroma  of  the  Rectum,  964 — 
Malignant  Tumors,  968 — Obstruction  from  Compression,  974 — 
Dynamic  Obstruction,  975 — Obstruction  after  Abdominal  Section, 
980. 

CHAPTER  XXVI. 

Strangulated  Hernia 983 

Etiology,  983 — Symptoms  and  Diagnosis,  985 — Prognosis,  988— 
Treatment,  989. 

CHAPTER    XXVII. 

Intestinal  Fistula 1004 

Etiology,  1005 — Treatment,  ion — Pathologic  Anatomy,  1012 — 
Surgical  Treatment,  10 14. 

CHAPTER    XXVIII. 

Resection  of  Joints 1024 

General  Directions  for  Joint  Resection,  1030 — Resection  of  Special 
Joints,  1033. 

CHAPTER  XXIX. 

Amputations  and  Disarticulations 1059 

Indications  for  Amputation,  1060 — General  Technic  of  Amputa- 
tion, 1065 — Amputation  of  the  Upper  Extremity,  1081 — Amputa- 
tion of  the  Arm,  1086 — Exarticulation  of  the  Entire  Upper  Ex- 
tremity, Including  the  Scapula  and  Clavicle,  1088 — Amputation  of 
the  Lower  Extremity,  1089 — Amputation  of  Toes,  1089 — Disar- 
ticulation of  all  the  Toes,  100 1 — Amputation  Through  the  Meta- 
tarsus, 109 1 — Mediotarsal  Disarticulation,  1092 — Malgaigne's 
Subastragaloid  Disarticulation,  1094— Syme's  Amputation 
Through  the  Ankle-joint  with  Excision  of  the  Malleoli,  1094 — 
Pirogoff's  Amputation,  1094 — Amputation  of  the  Leg,  1096 — 
Amputation  of  the  Thigh,  1105 — Disarticulation  at  the  Hip-joint, 

Index 1107 


Practical  Surgery 


PRACTICAL  SURGERY. 


CHAPTER    I. 

EMERGENCY  AND  MILITARY  SURGERY, 

Emergexcv  surgery  may  be  defined  as  the  application  of  manipu- 
lations or  the  performance  of  operations  in  the  treatment  of  accidents 
or  hfe -threatening  affections  amenable  only  to  prompt  surgical  in- 
terference. Emergency  surgery  is  the  surgery  of  the  general  prac- 
titioner. Every  physician  qualified  to  practise  his  profession  should 
have  the  necessary  knowledge  and  manual  dexterity  to  perform,  at 
a  moment's  notice  and  with  the  simplest  instruments  and  limited 
assistance,  all  life-saving  operations  in  all  cases  demanding  prompt 
action  to  meet  the  urgent  indications.  In  large  cities  the  medical 
practitioner  can  secure  the  services  of  a  professional  surgeon  with- 
out much  loss  of  time,  but  occasionally  he  will  be  confronted  by  a 
case  in  which  he  has  to  act  promptly  in  order  to  save  life.  Never- 
theless, the  mass  of  general  practitioners  throughout  the  country 
are  frequently  thrown  upon  their  own  resources,  and  must  be  pre- 
pared to  perform  the  most  difficult  operations  when  the  loss  of  time 
necessary  to  secure  surgical  aid  would  jeopardize  the  life  of  the 
patient. 

A  fair  percentage  of  the  practice  and  income  of  the  village  and 
country  practitioners  consists  of,  and  is  derived  from,  emergency 
work.  The  average  medical  student  is  more  interested  in  surgery 
than  in  medicine,  and  I  am  sure  the  surgical  training  he  receives 
ought  to  qualify  him  to  practise  emergency  surgery  with  credit  to 
himself  and  benefit  to  his  patients.  As  a  rule,  most  of  the  accident 
cases  and  acute  surgical  diseases  requiring  prompt  operative  treat- 
ment first  come  to  the  attention  of  the  general  practitioner,  who 
often  determines,  by  the  first  aid  rendered,  the  fate  of  the  patient. 
Neglect  and  mistakes  made  in  such  instances  arc  often  difficult  to 
balance  and  correct  later.  The  general  practitioner  mu.st  be  familiar 
with  surgical  diagnosis,  and  must  acquire  surgical  technic  suffi- 
ciently to  act  timely,  wi.sely,  and  safely  in  all  surgical  ca.ses  in 
which  immediate  interference  is  an  absolute  necessity  to  .save  life  or 
to  protect  the  patient  against  remote  di.sa.strous  comj)lications.  No 
phy.sician  should  receive  his  diploma  or  practi.se  his  professif)n  un- 
less he  is  fully  qualified  to  meetthe.se  requirements.  Surgery  mu.st 
often  be  practised  not  as  a  matter  of  choice,  but  of  necessity.  Per- 
haps the  best  definition  ever  given  of  a  surgeon  is  that  expres.scd 
2  17 


1 8  EMERGENCY    AND    MILITARY    SURGERY. 

in  the  words  of  Sir  Spencer  Wells  :  "A  surgeon  is  a  physician  who 
can  operate." 

The  profession  of  our  country  at  this  time  is  suffering  from  two 
great  defects  :  physicians  are  too  exclusively  physicians,  and  sur- 
geons are  too  exclusively  surgeons.  These  defects  must  be  reme- 
died if  our  profession  is  to  reach  the  highest  standard  of  efficiency 
and  utility.  The  medical  man  must  take  postgraduate  instruction 
in  surgery  and  subscribe  for,  read,  and  study  surgical  literature  if  he 
wants  to  be  just  to  his  high  calling  and  honest  to  his  clients.  On 
the  other  hand,  the  surgeon,  if  he  wants  to  practise  his  art  with  suc- 
cess and  credit  to  himself  and  his  craft,  must  pursue  an  opposite 
course.  One-sided  reading,  learning,  and  working  are  harmful  in 
the  practice  of  our  profession,  and  are  responsible  for  many  blunders 
in  the  practice  of  men  who  devote  their  time  and  attention  exclu- 
sively either  to  medicine  or  surgery.  There  should  be  no  such 
thing  as  exclusive  specialty  in  our  profession.  There  are,  and 
should  be,  specialists,  but  such  specialists  should  be  well  versed  in 
the  principles  of  medicine  and  surgery,  as  without  such  knowledge 
their  work  is  unsatisfactory  and  often  dangerous.  A  successful 
specialist  must,  above  all  things,  be  a  doctor  if  he  wants  to  make 
any  claim  upon  the  profession  or  command  the  confidence  of  the 
public.  Emergency  cases  occur  everywhere  and  at  all  times. 
They  are  the  cases  that  interest  the  public  most,  and  a  rush  is 
made  for  the  nearest  physician's  office,  the  inmate  being  expected 
to  respond  at  once  and  render  the  necessary  aid.  Every  physician 
thus  peremptorily  summoned  is  expected  to  be  master  of  the  situa- 
tion and  do  what  is  necessary.  Such  cases  often  come  to  our  recent 
graduates  who  are  not  overburdened  with  engagements.  Many  an 
eminent  practitioner  owes  his  early  success  to  prompt  and  intelli- 
gent treatment  of  such  cases.  On  the  other  hand,  many  a  young 
physician  has  injured  his  professional  career  by  his  early  unfavor- 
able experience  with  such  cases.  Again,  many  a  practitioner  of 
long  experience  and  with  a  lucrative  practice,  but  who  failed  to 
keep  step  with  the  progress  of  surgery,  has  found  his  practice  grad- 
ually melting  away  and  passing  into  the  hands  of  younger  and  more 
competent  men  because  of  his  shortcomings  in  emergency  work. 

If,  as  stated  before,  life  and  limb  in  accident  cases  often  depend 
on  the  manner  in  which  the  first  aid  is  rendered,  the  importance  of 
emergency  work  becomes  apparent.  Every  graduate  in  medicine 
must  be  qualified  to  do  satisfactory  service  in  emergency  cases,  re- 
gardless of  the  position  he  may  occupy  in  the  profession  or  the 
branch  of  medicine  or  surgery  he  may  have  chosen  for  his  vocation. 
If  this  is  the  case,  it  is  evident  that  this  department  of  surgery 
should  receive  more  time  and  attention  in  the  curriculum  of  our 
medical  colleges  and  postgraduate  institutions.  The  student  should 
first  receive  thorough  instruction  in  surgical  diagnosis.  This  part 
of  his  education  can  not  be  obtained  from  reading  and  lectures  with 
a  sufficient  degree  of  thoroughness  to  enable  him  to  interpret  in- 


EMERGENCY    SURGERY. 


19 


telligently  the  signs  and  symptoms  at  the  bedside.  This  branch  of 
the  teaching  must  be  largely  of  a  clinical  nature.  The  actual  con- 
tact with  patients,  s\-stematic  and  thorough  examination  under  the 
supervision  of  the  teacher,  will  prove  of  more  practical  value  in  the 
recognition  of  the  nature  of  injuries  and  disease  than  any  amount  of 
book-knowledge.  In  my  own  college  work  I  devote  one-third  of 
the  term  of  nine  months  to  surgical  diagnosis,  an  equal  amount  of 
time  to  emergency  surgery,  and  the  balance  of  the  term  is  occupied 
by  demonstrating  regional  surgery.  F'evv  of  the  graduates  become 
professional  surgeons,  hence  it  is  a  loss  of  valuable  time  to  dwell  at 
too  great  length  and  detail  on  the  description  and  demonstration  of 
many  of  the  major  operations  that  few  will  have  the  inclination  or 
opportunity  to  perform.  The  few  who  are  desirous  to  devote  them- 
selves to  surgery  exclusively  must  acquire  the  necessary  proficiency 
later  by  hospital  work  and  postgraduate  instruction.  It  is  a  serious 
mistake  for  any  recent  graduate  to  limit  his  work  to  surgery  exclu- 
sively. A  surgical  career  should  be  preceded  by  general  prac- 
tice for  a  period  of  at  least  five  years.  It  is  the  business  of  every 
medical  college  to  educate  physicians  in  such  a  way  as  to  make 
them  competent  to  do  ordinary  surgical  work  ;  it  is  not  expected 
to  produce  professional  surgeons.  No  student  should  be  permitted 
to  graduate  who  is  not  familiar  with  the  principles  of  surgery, 
surgical  diagnosis,  fractures  and  dislocations,  and  who  has  not  a 
comprehensive  knowledge  of  the  treatment  of  wounds  and  the 
technic  of  emergency  operations.  In  Rush  Medical  College,  in 
which  I  have  the  honor  to  teach  surgery,  I  describe  in  detail  all 
emergency  operations  and  perform  them  on  the  cadaver.  After 
this  has  been  done  each  student  performs  every  one  of  these  opera- 
tions under  the  supervision  of  a  competent  corps  of  demonstrators. 
The  ground  is  thus  gone  over  twice  in  a  systematic  way,  supple- 
mented repeatedly  in  the  clinics.  Orthopedic  appliances,  minor 
surgery,  and  bandaging  constitute  separate  departments  in  charge 
of  two  assistant  professors.  The  .students  make  their  own  splints 
and  dress  every  fracture,  using  manikin,  cadaver,  or  the  living  sub- 
ject for  this  purpose.  They  are  taught  how  to  sharpen  and  take 
care  of  instruments.  Ilemostasis,  suturing,  and  the  dressing  of 
wounds  receive  special  attention. 

Many  clinical  teachers  are  not  happy  unless  they  can  perform 
capital  operations  at  every  clinic  ;  they  are  anxious  to  show  what 
modern  aggressive  surgery  can  accomplish  and  what  they  can  do. 
The  teacher  of  clinical  surgery  often  forgets  that  he  is  teaching, 
and  sim[>ly  operates.  The  average  medical  student  has  the  pro- 
foundest  respect  and  admiration  for  such  a  teacher,  but  finds,  when 
thrown  on  his  own  resources,  that  he  has  learned  but  little.  The 
ideal  clinical  teacher  imparts  his  knowledge  to  the  .students,  and 
utih'zcs  to  greatest  advantage  that  kind  of  clinical  material  which 
will  come  under  the  care  of  the  general  practitioner. 

Emergency  work  and  minor  surgery  are  the  sui)jects  in  which 


20  EMERGENCY    AND    MILITARY    SURGERY. 

students  must  be  made  to  take  a  keen  interest,  and  which  should 
occupy  a  liberal  share  of  the  time  devoted  to  didactic  and  clinical 
teaching  of  surgery.  Emergency  work  demands  special  preparation, 
as  it  is  work  which  must  be  done  on  the  spur  of  the  moment,  with- 
out an  opportunity  of  making  special  preparations.  Besides  the 
acquisition  of  the  necessary  theoretic  and  practical  knowledge,  the 
physician  who  succeeds  the  best  in  the  practice  of  this  part  of  his  pro- 
fession is  the  one  who  is  also  in  possession  of  a  liberal  amount  of 
what  is  ordinarily  known  as  common  sense.  Many  highly  educated 
physicians  prove  failures  as  practitioners  because  they  lack  this 
natural  gift,  while  others,  less  learned  and  less  studious,  succeed 
because  they  were  born  with  a  special  aptitude  for  the  profession. 
Hard  study  and  constant  application  may,  in  the  course  of  time, 
balance  this  disadvantage,  but  they  will  never  entirely  overcome  it. 
Good  common  sense  is  of  special  importance  in  the  successful  prac- 
tice of  emergency  surgery.  Emergency  cases  require  immediate 
attention,  as  there  is  no  time  to  consult  text-books  and  often  no 
opportunity  to  obtain  a  consultant  or  to  secure  intelligent  assistance. 
Semper  paratns  is  the  key-note  to  success  in  the  practice  of  this 
department  of  surgery.  Emergency  work  implies  hasty,  and  yet 
careful,  work.  What  is  to  be  done  must  be  done  at  once.  The 
excitement  which  often  surrounds  such  cases  should  not  disturb  the 
calmness  of  the  physician.  The  physician  is  calm,  self-possessed, 
and  confident  if  he  is  conscious  that  he  is  master  of  the  situation. 

Originality  and  ingenuity  are  qualities  essential  to  the  success- 
ful practice  of  emergency  w^ork.  The  physician  who  can  perform 
difficult  operations  with  the  least  number  of  instruments,  without 
assistance,  and  who  can  extemporize  the  dressings  out  of  the  sim- 
plest materials,  is  the  one  who  will  never  be  at  a  loss  when  unex- 
pectedly confronted  by  a  difficult  case.  Quickness  of  perception, 
ready  resource,  decision  and  promptness  of  action,  characterize  the 
successful  emergency  surgeon.  The  physician  who  is  qualified 
to  practise  accidental  surgery  successfully  never  forgets  that  he 
must  keep  himself  always  in  readiness  to  respond  to  an  urgent  mes- 
sage. The  few  instruments  necessary  for  this  purpose  are  kept  in 
a  faultless  condition  in  a  canvas  cover.  His  emergency  bag  con- 
tains an  ample  supply  of  dressing  material,  antiseptics  in  tablet 
form,  reliable  ligature  and  suture  material,  anesthetics,  stimulants, 
and  a  small  medicine  case  ;  a  hypodermic  syringe,  a  good  supply  of 
rubber  tubing,  and  a  Davidson's  syringe  complete  the  most  neces- 
sary outfit. 

As  military  surgery  consists  largely  of  emergency  surgery 
under  the  most  trying  circumstances,  it  may  not  be  out  of  place 
to  discuss  here  briefly — 

The  Qualifications  and  Duties  of  the  Military  Surgeon. — 
That  every  military  surgeon  should  be  well  trained  in  emergency 
work  must  be  taken  for  granted.  His  surgical  work  in  the  field 
is  Hmited   almost  entirely  to  the  treatment  of  accidental  wounds. 


MILITARY    SURGERY.  21 

He  is  seldom  called  upon  to  perform  major  operations  for  any 
other  indication.  In  this  countiy,  owing  to  the  small  standing- 
army,  a  large  part  of  the  medical  service  devolves  upon  physicians 
from  civil  life,  and  our  experience  during  the  Spanish-American  war 
has  demonstrated  many  of  the  shortcomings  of  those  men  who  too 
suddenly  exchanged  their  civil  for  a  military  practice. 

Nearly  five  months  of  continuous  service  with  the  army  in  the 
camp  and  field  have  afforded  me  an  excellent  opportunity  to  make 
a  practical  study  of  the  subject.  This  time  was  spent  in  Camp 
Tanner,  Springfield,  111.  ;  Camp  George  H.  Thomas,  Chickamauga, 
Ga.  ;  Camp  Wikofif,  at  Montauk  Point,  L.  I.,  and  tiie  Cuban  and 
Porto  Rican  campaigns.  The  first  four  weeks  were  occupied  in 
Camp  Tanner,  where  I  assisted  in  the  capacity  of  surgeon-general 
of  the  State  in  the  organization  of  the  State  troops.  This  service 
brought  me  into  closer  contact  with  the  National  Guard  of  Illinois 
than  at  any  time  before.  A  physical  and  professional  examination  in 
which  I  took  part  brought  out  the  shady  as  well  as  the  sunny  side 
of  the  qualifications  of  the  medical  officers  of  my  State.  The  result 
of  my  experience  here  convinced  me  that  the  average  National 
Guard  surgeon  is  a  faithful  doctor,  with  more  than  average  profes- 
sional ability,  but,  with  few  exceptions,  lacking  the  neces.sary  mili- 
tary training  in  performing  satisfactorily  his  administrative  duties. 
This  is  a  part  of  his  education  that  has  been  sadly  neglected  in  the 
past  and  should  receive  more  attention  in  the  future.  Very  few 
States  make  provision  for  physical  examination  of  the  medical  offi- 
cers, consequently  some  of  them  have  entered  the  service  totally 
disqualified  for  participating  in  an  active  campaign.  Two  of  the 
candidates  for  tlie  volunteer  .service  from  the  National  Guard  of  Illi- 
nois were  rejected  on  this  ground. 

The  exacting  and  often  onerous  duties  of  the  military  surgeon 
in  time  of  war  require  special  qualifications  to  prepare  and  fit  him 
for  his  work.  He  is  not  only  expected  to  be  well  versed  in  theo- 
retic and  practical  knowledge  of  everything  pertaining  to  the  prac- 
tice of  medicine  and  surgery,  but  he  must  be  endowed  with  quali- 
ties both  of  mind  and  body  upon  which  he  can  rely  when  engaged 
under  the  most  trying  circumstances.  In  field  work  he  has  often  to 
perform  the  most  difficult  tasks  with  very  limited  resources.  In  such 
instances  good  common  sense  and  deliberate  action  go  much  fur- 
ther in  accomplishing  what  is  desired  than  the  finest  scholarship 
and  the  most  profound  logical  reasoning.  The  man  who  can  in  a 
few  moments  extemporize  a  well-fitting  splint  out  of  the  simplest 
materials,  and  perform  with  the  contents  of  an  ordinary  pocket-ca.se 
the  mo.st  difficult  operation,  will  do  vastly  better  vvf)rk  on  the  battle- 
field than  mo.st  professors  of  surgery  and  the  most  brilliant  opera- 
tors in  civil  practice.  The  surgeon  who  understands  the  jjrinciples 
and  practice  of  good  cooking  is  of  more  service  to  the  troops  than 
the  one  who  can  repeat,  word  for  word,  the  contents  of  the  most 
exhaustive  treati.sc  on  materia  medica  and  tlurai)eutics.     'I'he  med- 


22  EMERGENCY    AND    MILITARY    SURGERY. 

ical  officer  with  a  full  knowledge  of  hygiene  and  sanitation  and  en- 
dowed with  the  faculty  of  making  a  rational,  practical  use  of  it  is 
preferable  to  the  most  expert  clinician,  as  in  military  practice  it  is 
more  important  to  prevent  than  to  treat  disease,  no  matter  how  suc- 
cessfully and  scientifically  the  latter  may  be  conducted.  The  all- 
around  medical  officer  must  be  a  good  mechanic  :  he  should  know 
how  to  use  the  carpenter's  and  blacksmith's  tools,  how  to  row  and  sail 
a  boat,  how  to  make  a  raft,  and  occasionally  he  will  have  reason  to 
be  thankful  if  he  has  learned  how  to  pack  a  mule  and  drive  an  am- 
bulance team.  His  miscellaneous  knowledge  of  matters  and  things 
entirely  outside  of  his  legitimate  province  will  be  constantly  drawn 
upon  from  different  sources,  and  the  more  he  knows  and  is  willing  to 
impart,  the  more  he  will  be  useful  and  popular.  The  man  who  en- 
ters the  medical  department  of  the  army  under  an  impression  that 
he  is  only  expected  to  treat  wounds,  set  broken  bones,  and  prescribe 
for  the  ordinary  camp  ailments  makes  a  serious  mistake  and  will 
surely  be  a  disappointment  to  himself  and  to  those  he  is  expected 
to  serve. 

Physical  Condition. — The  ideal  military  surgeon  in  possession 
of  the  necessary  mental  and  physical  qualities  to  make  him  such 
is  seldom  seen.  The  most  active  brains  are  often  found  in  frail 
bodies.  I  have  often  seen  in  civil  life  surgeons  of  great  reputation 
struggling  with  disease  or  its  effects,  or  the  victims  of  some  congenital 
or  acquired  defects,  who  were  wonders  in  the  operating  amphitheater 
in  spite  of  some  disability.  I  have  seen,  more  than  once,  the  sad- 
dest of  all  spectacles  in  professional  life — a  surgeon  himself  the 
subject  of  an  incurable  disease  muster  into  service  every  particle  of 
his  reserve  strength  to  perform  a  critical  operation  with  the  view  to 
saving  the  life  of  another.  Achievements  of  this  kind  are  possible 
in  private  practice,  but  are  entirely  out  of  the  question  in  military 
service.  The  physical  condition  of  the  military  surgeon  must  be 
as  nearly  perfect  as  possible.  A  physical  examination  as  thorough 
and  as  painstaking  as  in  the  case  of  a  private  can  only  decide  upon 
the  necessary  physical  qualifications  of  candidates  for  commission 
in  the  medical  service.  For  good  reasons  this  rule  is  followed  in  the 
selection  of  medical  officers  for  the  regular  army,  and  there  is  no 
ground  why  the  same  requirements  should  not  be  exacted  in  the 
National  Guard.  During  my  service  at  Chickamauga,  Montauk, 
and  at  the  front,  I  saw  more  than  one  volunteer  surgeon  who  ought 
to  have  been  excluded  from  the  service  for  physical  disability. 
During  a  campaign  the  loss  of  a  single  medical  officer  may  prove  a 
great  disaster.  Of  all  commissioned  officers,  the  surgeon  is  the 
most  indispensable.  The  vacant  place  of  a  line  officer  can  be  filled 
at  a  moment's  notice  without  any  serious  loss  to  the  service  ;  not 
so  with  the  surgeon.  His  position  is  one  requiring  special  training, 
and  one  that  can  not  be  filled  without  crippling  the  medical  service 
at  some  other  point.  For  this,  if  for  no  other,  reason  the  medical 
officer  must  be  in  sound  health  and  able  to  cope  successfully  with 


MENTAL    QUALIFICATIONS.  23 

the  hardships  of  a  campaign.  In  battle  and  during  the  prevalence 
of  an  endemic  or  epidemic  disease  the  medical  officer  is  the  one 
above  all  others  whose  strength  and  endurance  are  taxed  to  their 
utmost  extent.  His  services  are  required  by  day  and  by  night. 
He  has  no  rest,  and  unless  in  possession  of  an  iron  constitution  his 
strength  fails  him  and  he  becomes,  if  not  a  fit  subject  for  the  hos- 
pital, at  least  a  physical  wreck,  who,  if  he  persists  in  continuing 
his  work,  will  often  do  more  harm  than  good.  A  number  of  such 
instances  came  to  my  personal  notice  during  the  Cuban  campaign. 
A  medical  officer  should  not  only  be  in  full  possession  of  health 
and  all  that  this  implies,  but  he  should  have  been  in  training  to 
endure  hardships  of  all  kinds  from  early  childhood.  He  need  not 
necessarily  be  an  athlete,  but  he  should  be  able  to  walk  twenty 
miles  a  day  or  ride  forty  without  fatigue,  and  then  be  ready  to  do  a 
night's  work  should  an  emergency  demand  it.  The  dancing-halls 
and  club-houses  are  poor  training-schools  for  a  successful  military 
career.  The  labor  and  hardships  encountered  in  hunting  are  best 
calculated  to  prepare  the  body  for  a  life  of  great  activity  and  priva- 
tion. Frugal  living  will  not  only  prove  conducive  to  the  mainte- 
nance of  health,  but  will  be  the  best  means  of  initiating  the  surgeon 
to  the  uncertainties  of  the  commissary  department  when  on  the 
march  or  in  the  field. 

Let  every  one  who  chooses  a  military  career  dispense  with 
unnecessary  clothing  and  luxuries  during  early  life,  in  order  to 
accustom  and  adapt  himself  for  his  life-work,  which  in  time  of  war 
will  bring  the  inevitable  amount  of  vicissitudes  and  even  of  suffering. 
The  medical  officer  must  be  a  good  horseman,  which  here  not  only 
implies  a  good  rider,  but  includes  a  knowledge  of  the  usual  ailments 
of  horses,  the  treatment,  feeding,  and  care  of  the  animals.  To  sum  up, 
the  military  surgeon  must  be  a  man  of  vigor,  made  so  by  birth  and 
training,  with  as  few  requirements  in  his  habits  of  living  as  possible, 
in  order  that  he  may  resist  to  the  highest  degree  the  influences  of 
climate  and  di.sease,  and  prepare  himself  for  tlie  hardships  and  j)ri- 
vations  incident  to  active  warfare. 

Mental  Oualifications. — A  proper  and  adequate  preliminary 
education  is  exacted  of  every  surgeon  in  the  regular  army  ;  without 
it  he  is  not  permitted  to  pass  the  medical  examination.  Statistics 
show  that  a  large  percentage  of  the  candidates  are  dropped  at  this 
stage  of  the  examination.  This  is  a  reflection  on  the  system  of 
medical  examination  which  continues  to  prevail  in  our  country. 
About  the  only  evidence  of  proficiency  the  National  Guard  surgeon 
in  most  of  our  .States  is  required  to  show  is  his  diploma.  It  makes 
but  little  difference  where  the  diploma  was  obtained.  Kvidences  of 
a  .satisfactory  preliminary  education  are  not  required  in  most  of  the 
States.  In  con.sequence  of  .so  easy  an  entrance  into  the  medical 
.service  of  our  State  troops  many  of  the  men  who  receive  commis- 
.sions  are  illiterate.  I^y  hard  ()ostgraduate  work  they  often  become 
good  physicians,  but  they  seldom,  if  ever,  make   up  for  the  early 


24'  EMERGENCY    AND    MILITARY    SURGERY. 

defects  of  their  education,  which  seriously  interfere  with  a  successful 
military  career.  Is  it  to  be  wondered  at  that  when  such  shortcom- 
ings are  discovered  by  their  colleagues  and  officers  of  the  line,  they 
do  not  command  the  respect  to  which  their  commissions  should 
entitle  them  ?  The  reports  made  out  by  such  men  speak  for  them- 
selves, and  appear  as  black  stains  upon  the  department  they  repre- 
sent. The  elevation  of  the  standard  of  medical  education  by  most 
of  the  medical  schools  throughout  the  country  will,  gradually  wipe 
out  this  blemish,  but  it  will  be  many  years  before  all  the  diplomas 
can  be  accepted  as  sufficient  proof  that  their  possessors  are  entitled 
to  recognition  by  the  medical  department  of  the  different  States. 
Let  us  hope  that  a  speedy  and  radical  reform  may  be  instituted  in 
the  different  States  which  will  accomplish  the  desired  object,  and 
which  will  make  the  commission  of  a  medical  officer  of  greater  im- 
port in  showing  a  higher  degree  of  preliminary  and  professional 
proficiency  than  the  diploma  of  any  of  our  medical  colleges.  This 
is  a  desideratum  for  the  realization  of  which  every  one  interested  in 
the  success  and  usefulness  of  the  National  Guard  should  willingly 
use  his  influence. 

Fortunately,  there  are  no  specialties  in  military  practice.  The 
medical  education  of  a  military  surgeon  must  be  of  the  most  liberal 
and  broadest  kind.  His  practice  is  so  varied  that  he  may  have  to 
be  physician,  surgeon,  ocuHst,  aurist,  etc.,  the  same  day.  The  sphere 
of  the  regular  army  surgeon  serving  at  a  post  includes  in  addition 
obstetrics,  gynecology,  and  diseases  of  children.  Every  military 
surgeon  must  be  an  expert  in  physical  diagnosis  and  examination 
of  the  eye  and  ear.  He  must  know  something  about  dentistry  :  he 
must  know  how  to  extract  teeth  and  how  to  put  in  a  temporary 
filling  in  a  carious  tooth  that  can  be  saved.  He  must  be  familiar 
Avith  neurology,  the  use  and  application  of  electricity  as  a  diagnostic 
and  therapeutic  resource.  In  camp  and  field  he  is  limited  to  his  own 
resources  in  the  diagnosis  and  treatment  of  all  kinds  of  injuries  and 
diseases.  He  must,  therefore,  be  well  equipped  with  a  thorough 
knowledge  of  everything  pertaining  to  surgery  and  medicine,  and  is 
often  called  upon  to  represent  the  different  specialties.  No  amount 
of  preliminary  and  professional  education  will  make  the  military 
surgeon  an  efficient  officer  unless  he  is  possessed  of  an  inborn  apti- 
tude for  the  profession.  H^e  must  be  able  to  apply  and  make  use 
of  his  knowledge.  Many  men  of  great  learning  never  become  suc- 
cessful practitioners.  Their  store  of  knowledge  fails  them  when 
they  come  to  apply  it.  The  military  surgeon  in  camp  and  field  must 
be  a  man  of  quick  perception.  He  must  be  able  to  recognize 
malingering  as  well  as  disease.  In  an  emergency  he  must  be  in 
readiness  to  act  intelligently  at  a  moment's  notice.  Hesitation  is 
dangerous  both  to  the  patient  and  the  reputation  and  good  standing 
of  the  surgeon.  Indecision  creates  mistrust,  procrastination,  disas- 
ter. Quick  decision  and  prompt  action  are  the  essential  prerequis- 
ites  of  successful   emergency  work.      Successful   action,   however, 


PUNCTUALITY.  25 

must  be  preceded  by  thoughtful,  systematic  preparation.  The  most 
successful  surgeon  is  the  one  who  adopts  and  follows  the  watchword, 
semper  paratus.  He  should  never  be  caught  napping.  Careful 
preparation  makes  prompt  action  possible.  The  successful  surgeon 
makes  his  plans  ahead,  and  supplies  himself  with  the  necessary  out- 
fit, medicines,  dressing  materials,  and  instruments  before  the  emer- 
gency arises,  and  when  it  does  so,  he  is  fully  prepared  to  meet  it. 
A  lack  of  forethought  and  systematic  preparation  accounts  for  many 
shortcomings  of  medical  officers  in  the  field  and  camp,  with  the 
necessary  evil  consequences  for  those  intrusted  to  their  care. 

Military  Spirit. — Any  one  who  adopts  the  medical  service  of 
the  army  as  a  life  vocation  will  be  disappointed  unless  he  does  so 
imbued  with  a  proper  military  spirit.  The  military  surgeon  must 
be  a  military  man  and  an  integral  part  of  the  army  if  he  wants  to 
do  justice  to  his  calling  and  the  department  he  represents.  I  fear 
it  is  a  lack  of  the  proper  military  spirit  in  some  of  the  medical 
officers  in  the  regular  army  that  is  responsible  for  a  well-recogniz- 
able cleft  between  them  and  the  officers  of  the  line  and  field.  If 
this  is  true  in  the  regular  army,  it  is  only  too  obvious  in  the  National 
Guard.  The  rank  of  the  medical  officers  and  their  standing  in 
military  and  social  circles  suffer  when  they  are  regarded  and  treated 
as  ordinary  doctors.  The  West  Point  graduate,  educated  at  the 
expense  of  the  Government,  too  often  forgets  that  it  takes  more  hard 
work  and  a  longer  time  to  make  a  good  doctor  than  an  officer.  The 
officers  of  the  National  Guard,  holding  commission  by  the  grace 
of  their  Governor,  do  not  realize  sufficiently  that  their  military  sur- 
geons have  spent  a  small  fortune  and  five  years  in  acquiring  a 
knowledge  of  their  profession.  They  seem  to  forget,  or  at  any  rate 
often  ignore,  that  when  they  go  into  camp  or  in  the  field  they  do 
so  at  a  great  personal  and  pecuniary  sacrifice.  Their  absence  from 
home,  even  for  a  short  time,  may  cause  a  break  in  their  practice 
difficult  to  repair.  The  medical  officer  is  entitled  to  recognition  as 
a  military  man,  and  if  this  is  not  accorded  to  him  voluntarily,  he 
must  resort  to  measures  that  will  enforce  it.  The  lack  of  military 
dignity  on  the  part  of  the  medical  staff  is  due  largely  to  a  lack  of 
the  projDcr  military  spirit  in  the  members  which  compose  it,  and  to 
too  great  a  familiarity  between  the  surgeons  and  the  officers  and  men. 
The  correction  of  these  evils  can  not  be  undertaken  too  soon,  and 
when  accomplished,  will  add  much  to  the  dignit)^  influence,  and 
efficiency  of  tlie  medical  dejiartment  of  the  army  and  State  troops. 

The  medical  officer  who  has  enjoyed  the  advantages  of  an  early 
military  training  in  a  military  academy  or  in  the  National  Guard  is 
the  one  best  qualified  to  enforce  mlHtary  rules  and  assert  the  dignity 
of  his  jjosition. 

Punctuality. — The  busiest  men  have  always  the  most  lime  to 
perform  a  duty  or  to  meet  an  engagement  at  the  appointed  time. 
This  rule  holds  good  in  all  walks  of  life.  The  drones  are  always 
behind.      In  military  life  punctuality   means   everything,  and  from 


26  EMERGENCY    AND    MILITARY    SURGERY. 

this  exaction  the  medical  officer  should  never  be  excluded  except 
for  special  and  well-founded  reasons.  In  the  regular  army  there  is 
a  way  of  disciplining  the  medical  as  well  as  other  officers  in  coming 
to  time  in  the  performance  of  definite  duties  and  in  making  out  the 
reports.  My  long  experience  in  the  National  Guard  service  has 
taught  me,  occasionally  in  a  painful  way,  that  the  surgeons  are 
often  entirely  oblivious  to  the  matter  of  time,  especially  when  called 
upon  to  make  out  and  transmit  the  regimental  reports.  It  is  the 
men  who  put  off  for  to-morrow  what  should  be  done  to-day,  and 
who  meet  their  engagements  at  one  o'clock  or  thereafter  instead 
of  at  twelve,  who  fill  the  lives  of  their  superior  officers  with  mis- 
ery and  disappointment.  The  men  that  accomplish  the  most  are. 
always  ready  and  on  time.  The  medical  officers  must  be  made 
to  understand  that  a  due  regard  for  punctuality  in  performing  their 
duties,  in  meeting  appointments,  and  in  making  out  and  forward- 
ing reports  is  one  of  the  most  essential  features  of  a  successful 
military  career. 

Courage. — It  is  still  the  general  belief  that  in  times  of  war 
the  military  surgeon  is  exposed  to  less  danger  than  the  soldiers  and 
officers  in  command.  That  this  is  not  so  is  shown  by  the  statistics 
of  all  wars.  Although  the  position  of  the  military  surgeon  is 
behind  the  fighting-line,  he  is  usually  near  enough  to  the  enemy 
when  serving  in  the  front  to  be  reached  by  stray  bullets  and  burst- 
ing shells.  The  number  of  surgeons  killed  and  wounded  in  the 
performance  of  their  duty  in  rendering  first  aid  is  by  no  means 
small  in  any  war  of  magnitude.  In  active  warfare,  however,  the 
greatest  danger  to  the  surgeons  is  to  be  found  in  their  constant 
exposure  to  contagious  and  infectious  diseases,  which  follow  large 
armies  in  all  climates  and  during  all  seasons  of  the  year.  To  enter 
a  yellow-fever  camp  to  my  mind  calls  for  more  courage  than  to 
lead  and  command  the  troops  in  the  battle-field.  Disease  always 
claims  more  victims  than  bullets,  and  this  was  especially  true 
of  the  war  with  Spain.  The  nation  worships  the  heroism  of  those 
who  fell  before  Santiago,  but  much  less  is  said  of  the  vastly  greater 
number  stricken  down  by  disease,  and  who  have  lost  their  lives  from 
disease,  often  after  prolonged  and  intense  suffering.  To  the  credit 
of  the  medical  officers  of  this  and  other  wars  it  must  be  said  that 
they  showed  no  fear,  either  in  facing  the  enemy  or,  what  is  vastly 
worse,  disease.  When  yellow  fever  made  its  appearance  among  the 
troops  around  Santiago,  every  man  remained  at  his  post  and  faced 
the  danger  without  fliinching.  Men  from  the  North  who  had  never 
seen  the  disease  accepted  the  detail  for  duty  in  the  fever  hospitals 
without  a  word  of  complaint.  The  medical  officer  must  be  endowed 
with  more  than  ordinary  courage  to  face  the  many  dangers  that 
surround  him  on  all  sides  during  a  campaign.  Patriotism  begets 
heroism,  and  I  make  a  well-founded  claim  for  both  for  the  medical 
profession  represented  in  the  army. 

Personal  Habits. — The  old  adage  that  "  It  is  easier  to  preach 


THE    MILITARY    SURGEON    IN    WAR.  27 

than  to  practise  "  is  a  familiar  one,  and  should  be  made  to  apply 
with  the  same  force  to  doctors  as  to  preachers.  The  first  and 
most  important  duty  of  the  military  surgeon  is  to  prevent  disease. 
This  can  often  be  done  more  effectively  b\'  example  than  b}-  talking 
or  issuing  orders.  The  military  surgeon  must  guard  the  camp 
against  disease.  He  is  looked  upon,  and  must  be  regarded  by 
those  under  his  care,  as  the  one  above  all  others  who  can  give 
them  advice  in  matters  pertaining  to  their  health.  He  is  expected 
to  do  this  by  example  as  well  as  by  teaching.  He  must  become  a 
permanent  object-lesson  in  inculcating  the  importance  of  cleanli- 
ness in  person  and  in  dress.  His  tent  should  be  the  cleanest  and 
most  orderly  in  camp.  Temperance  in  eating  and  drinking  can  be 
taught  more  successfully  by  action  than  by  words.  A  military 
surgeon  under  the  influence  of  liquor  will  do  more  harm  in  encour- 
aging the  vice  of  intemperance  than  can  be  undone  b\'  weeks  of 
lecturing.  Profanity  is  prevalent  in  every  camp,  and  while  it  is  not 
the  duty  of  the  surgeon  to  supplant  the  chaplain  in  suppressing  it, 
it  should  receive  no  encouragement  by  his  example.  In  his  conduct 
toward  the  men  the  surgeon  should  be  firm  and  dignified,  }'et  kind 
and  sympathetic,  especially  to  those  in  need  of  his  professional 
services.  An  impetuous  nature  and  an  irritable  temper  create  a 
rebellious  spirit,  which  it  is  difficult  to  control  by  the  most  ener- 
getic measures.  Proper  questions  should  be  answered  willingly 
and  with  sufficient  clearness  and  at  adequate  length  to  furnish  the 
desired  information,  and  not  gruffl\^  and  snappishly,  as  is  occasion- 
ally done  without  any  reason  or  provocation.  Overwork  and  a 
poor  digestion  are  poor  excu.ses  for  treating  a  subordinate  in  an 
undignified,  ungentlemanly  manner.  The  military  surgeon  must 
be  known  in  camp  as  a  gentleman,  not  only  by  the  officers,  but  by 
every  man  under  his  charge,  if  he  expects  to  be  respected  and  to 
do  justice  to  his  high  calling  and  responsible  position. 

The  Military  Surgeon  in  War. — The  true  qualities  of  the  mili- 
tary surgeon  are  cr\'stalli/.cd  and  best  shown  during  an  active 
campaign.  It  is  in  war  that  his  ready  resources  will  come  to  the 
surface  and  will  be  subjected  to  the  severest  tests.  It  is  in  battle 
and  during  the  prevalence  of  deva.stating  di.sea.ses  that  his  moral 
courage  and  physical  endurance  will  be  most  severely  tried.  It  is 
under  such  circum.stances  that  the  troops  will  reap  the  greatest 
benefits  from  the  skill,  diligence,  fortitude,  and  ready  resources  of  the 
medical  officer.  The  surgeon  who  can  extem])ori/.e  an  operating 
table  in  the  field,  who  can  secure  a.sepsis  with  the  use  of  the 
camp  kettle,  .soft  soap,  and  carbolic  acid  or  sublimate,  and  who 
can  perform  the  most  difficult  operations  with  the  sim|)lest  and 
fewest  instruments,  with  little  or  no  a.ssi.stance,  is  the  one  who 
will  accomplish  the  most  and  who  will  obtain  the  best  results  in 
the  field. 


CHAPTER  II. 

TRAUMATIC  SHOCK. 

Traumatic  shock  is  a  subject  of  great  importance  and  concern 
to  every  practical  surgeon.  He  observes  this  condition  frequently, 
either  as  the  immediate  result  of  an  injury  or  of  an  operation. 
We  are  forced  to  admit  that  very  little  has  been  added  to  our 
knowledge  of  shock  since  the  writings  of  Jordan,  Pirogoff,  and 
Groeningen.  The  experimental  work  done  so  far  and  the  clinical 
observations  made  afford  us  but  an  incomplete  insight  into  the 
nature  and  etiology  of  shock.  It  remains  for  the  experimental  in- 
vestigators of  the  future  to  forge  the  key  to  unlock  this  mysterious 
complication  of  injuries,  accidental  or  intentional.  As  the  clinical 
field  has  been  fairly  well  exhausted  without  any  striking  new  results 
being  obtained,  it  must  be  left  to  experimental  work  to  furnish  the 
necessary  information  regarding  the  nature  of  traumatic  shock. 
With  a  full  knowledge  of  the  essential  of  this  common  compli- 
cation of  all  grave  injuries  we  shall  be  in  a  better  position  to 
devise  more  efficient  prophylactic  measures,  and  to  produce,  select, 
and  apply  more  successful  therapeutic  resources. 

The  term  shock  originated  in  England,  where  this  earliest  of 
all  wound  complications  first  appears  to  have  attracted  attention. 
In  that  country  it  was  made  the  subject  of  special  study  by  Travers, 
Jordan,  and  Savory.  Pirogoff  described  what  is  now  generally 
known  and  understood  by  the  word  shock  as  traumatic  torpor  or 
wound  stupor.  The  conceptions  of  writers  on  shock  are  at  vari- 
ance in  reference  to  the  nature  of  that  condition.  I  say  condition, 
for  uncomplicated  shock  can  not  be  regarded  as  a  disease.  Savory 
describes  shock  as  a  paralyzing  influence  on  the  action  of  the  heart, 
due  to  a  sudden  and  severe  injury  of  the  nerves.  Jordan  defines  it 
as  a  peculiar  condition  of  the  animal  organism,  characterized  by 
arrest  of  all  functions,  caused  by  a  severe  influence  upon  the  cen- 
tral organs  or  a  considerable  portion  of  the  peripheral  distribution 
of  the  nervous  system.  Fischer,  in  his  classic  treatise  on  shock, 
attributes  it  to  weakness  of  the  heart's  action  caused  by  a  reflex 
vasomotor  paralysis,  whereby  the  large  abdominal  vessels  are  en- 
gorged with  blood,  and  the  surface,  heart,  brain,  and  other  organs 
are  correspondingly  ischemic.  Guthrie,  the  distinguished  military 
surgeon,  who  had  an  enormous  experience  with  gunshot  wounds, 
has  this  to  say  of  shock  :  "A  certain  constitutional  alarm  or  shock 
follows  every  serious  wound,  the  continuance  of  which  excites  a 
suspicion  of  its  dangerous  nature,  which  nothing  but  its  subsidence 
and  the  absence  of  symptoms  peculiar  to  the  internal  part  presumed 

28 


ETIOLOGY. 


29 


to  be  injured  should  remove.  The  opinion  given  under  such  cir- 
cumstances should  be  very  guarded,  for  if  tiiis  symptom  of  alarm 
should  continue,  grave  fears  maybe  entertained  of  hidden  mischief." 
Leyden  is  of  the  opinion  that  the  brain  does  not  participate  in 
shock,  and  the  mind  remains  clear — stupor,  coma,  and  delirium  are 
rarely  present.  Blum  interprets  shock  as  an  arrest  of  the  heart's 
action,  due  to  reflex  irritation  of  the  pneumogastric  nerve.  Groen- 
ingen  believes  that  the  spinal  cord  is  the  part  of  the  central  nervous 
system  principally  involved  in  the  production  of  symptoms  which 
characterize  shock.  He  says:  "The  spinal  cord  up  to  its  point 
of  origin  from  the  brain  is  suddenly  overwhelmed,  and  can  only 
regain  its  vitality  after  a  complete  rest."  Stevenson,  in  his  recent 
work  on  military  surgery,  alludes  to  shock  in  the  following  lan- 
guage :  "  It  is  characterized  by  prostration  or  collapse,  which  sets 
in  almost  immediately  after  an  injury  sufficient  in  intensit}- to  inhibit 
the  action  of  the  vasomotor  nerves." 

From  the  foregoing  definitions  and  opinions  of  shock  it  is  clear 
that  the  elucidation  of  this  subject  is  in  need  of  future  study  and  inves- 
tigation. The  confusion  is  increased  by  the  discussions  on  delayed 
or  protracted  and  local  shock.  Mr.  McLeod  affirms  that  he  has 
seen  several  cases  of  delayed  shock.  F.  H.  Hamilton  never  met 
with  such  an  example,  except  where  some  visceral  lesion  or  the 
rupture  of  a  large  blood-vessel  has  accompanied  the  accident. 
Very  few,  if  any,  surgeons  at  the  present  time  would  be  willing  to 
admit  that  they  had  ever  seen  a  case  of  secondary  shock.  The 
symptoms  that  led  some  of  the  older  surgeons  to  describe  dcla}'ed, 
protracted,  or  secondary  shock  resulted  not  from  the  immediate 
effects  of  the  injury  or  operation,  but  from  other  wound  complica- 
tions, such  as  acute  sepsis,  internal  hemorrhage,  or  fet  embolism. 
Pirogoff  was  the  first  one  to  describe  local  shock — "/«  stupeiir  locale!' 
Groeningen  defines  it  as  peripheral  shock  and  as  closely  allied  to 
what  is  more  commonly  observed  as  reflex  paralysis.  Berger  has 
seen  in  some  cases  a  complete  hemianesthesia.  The  anesthesia  is 
so  complete  that  operations  can  be  performed  without  causing  pain. 
Local  shock  is  nuxst  noticeable  in  recent  cases  of  gunshot  wounds. 
Immediately  or  soon  after  the  wound  has  been  received,  the  injured 
limb  can  be  freely  handled  and  the  wound  explored  without  a 
word  of  complaint  on  the  part  of  the  patient,  who  may  not  be  suf- 
fering to  any  extent  from  general  shock.  The  injured  limb  is  cool, 
skin  wrinkled  and  of  a  pale  bluish  color,  sen.sation  nearly  or 
entirely  abolished,  and  the  patient  often  complains  of  a  .sensation  of 
prickling  and  numbness.  Local  shock  was  frequently  observed 
among  the  wounded  at  .Santiago. 

Etiology. — From  what  has  been  .said  it  is  evident  that  the  com- 
plexus  of  symptoms  known  as  shock  is  the  result  of  the  immediate 
effect  of  the  injury.  In  the  ab.sence  of  hemorrhage  it  could  only 
be  explained  by  assuming  a  permanent  or  temporary  paralysis  of  a 
reflex  origin.     As  the  maximum  .symptoms   appear  at  once,  and 


30  TRAUMATIC    SHOCK. 

almost  instantly  upon  the  receipt  of  the.  injury,  we  can  safely 
exclude  any  toxic  or  mechanical  agent  circulating  in  the  blood  as  a 
cause  of  shock.  Individual  susceptibility  to  shock  plays  an  impor- 
tant role  in  the  etiology  of  this  complication  of  injuries.  The 
resisting  power  of  the  lower  animals  to  the  immediate  effects  of 
injuries  varies  greatly,  and  bears  a  direct  relation  to  the  degree  of 
development  of  the  nervous  system.  The  lower  the  scale  of 
development  of  the  nervous  system,  the  greater  the  resistance  to 
injuries  of  all  kinds.  The  tenacity  of  life  that  belongs  to  many 
species  of  amphibia  is  almost  proverbial.  The  heart  of  a  decapi- 
tated turtle  continues  to  beat  twenty-four  hours  or  more  after 
severing  the  brain  from  the  body.  Every  hunter  is  familiar  with 
the  variable  results  of  the  same  injuries  in  different  animals.  The 
alligator,  bear,  and  wild  turkey  are  hard  to  kill.  Unless  some 
vital  organ  is  injured,  these  animals  are  almost  sure  to  make  their 
escape.  The  delicate,  nervous  rabbit  is  an  easy  prey,  and  is  often 
bagged  after  receiving  a  comparatively  slight  injury.  The  sturdy 
mallard  duck  can  not  be  stopped  unless  mortally  wounded,  while 
the  sensitive  snipe  and  woodcock  give  up  the  struggle  for  life  upon 
the  receipt  of  insignificant  injuries.  In  man  the  condition  of  the 
nervous  system  constitutes  an  important  element  in  determining 
the  degree  of  shock.  A  high-strung,  nervous  temperament, 
hereditary  or  acquired,  constitutes  an  important  predisposing  cause 
to  shock.  A  sedentary  occupation  requiring  much  mental  labor  is 
another  element  conducive  to  the  occurrence  of  shock  from  com- 
paratively slight  injuries. 

Debilitating  diseases  and  mental  worry  or  anxiety  operate  in 
the  same  manner.  It  has  been  observed  that  in  warfare  homesick- 
ness and  defeat  do  more  to  favor  the  production  of  shock  than  the 
privations  incident  to  service  in  the  field.  Outdoor  life,  a  sufficient 
amount  of  physical  exercise,  plain  diet,  abstinence  or  moderate  use 
of  stimulants,  are  best  calculated  to  increase  the  resistance  to  shock 
in  the  case  of  injury  or  operation.  There  can  be  no  question  as 
to  the  influence  of  nationality  in  being  either  favorable  or  antago- 
nistic to  shock.  Civilization  increases  the  susceptibility  to  shock. 
The  North  American  Indian  and  the  negro  are  much  less  liable  to 
shock  than  the  descendants  of  the  European  races.  The  surgeon 
has  no  means  of  foretelling  the  immediate  effects  of  an  operation, 
as  he  is  unable  to  determine  beforehand  the  individual  susceptibility 
to  shock.  The  general  condition  and  appearance  of  the  patient 
can  not  be  relied  upon  in  estimating  the  immediate  effects  of  an 
operation  or  injury.  An  apparently  healthy,  robust  man  may 
suffer  more  from  shock  than  a  delicate  woman  would  from  the 
same  injury  or  operation.  Much  remains  to  be  learned  concern- 
ing the  state  of  the  nervous  system  in  favoring  or  resisting  shock. 
We  know  that  shock  is  liable  to  occur  in  proportion  to  the  degree 
of  irritability  of  the  nervous  centers.  Under  similar  circumstances 
it  is  pronounced   in   the  adult,  light   in    children  without  stormy 


ETIOLOGY. 


31 


manifestations,  and  grave  in  the  aged.  The  disparity  in  the  indi- 
vidual siisceptibiht\-  is  so  great  that  the  same  causes  do  not  always 
produce  the  same  clinical  picture. 

Experimental  research  has  contributed  much  to  explain  the 
etiology  of  shock,  but  much  remains  to  be  accomplished  in  the 
same  direction.  The  experiments  of  Goltz  have  shown  that  death 
in  frogs  results  from  arrest  of  the  heart-beat  in  the  diastole  by  mak- 
ing tapotement  (tapping)  over  the  region  of  the  stomach.  If  the 
experiment  is  made  short  of  permanently  arresting  the  heart's 
action  and  this  organ  resumes  its  function,  it  remains  small  and 
pale  and  receives  during  the  diastole  only  a  small  quantity  of 
blood  ;  hence  the  general  circulation  stagnates  even  if  the  heart  con- 
tinues to  contract.  If  the  animal  recovers,  it  requires  half  an  hour 
before  the  circulation  is  restored.  Goltz  attributes  the  cardiac  in- 
efficiency to  a  temporary  paralysis  of  the  tonus  of  the  vessels, 
caused  by  the  concussion  of  the  abdominal  viscera  from  the  blows 
over  the  abdomen. 

Later,  however,  he  came  to  the  conclusion  that  the  vascular 
paresis  is  not  limited  to  the  abdominal  viscera  injured  by  the 
tapotement,  but  that  it  affects  all  the  blood-vessels.  It  was  demon- 
strated by  experiment  that  concussion  of  the  entire  body  gave  rise 
to  the  same  vascular  paralysis.  His  experiments  proved  likewise 
that  the  veins,  as  well  as  the  arteries,  are  affected  by  the  paralysis. 
These  experiments  would  tend  to  prove  that  shock  is  the  result  of 
a  reflex  paralysis  of  the  vasomotor  nerves,  caused  by  a  traumatic 
concussion  of  a  part  of  or  the  entire  body.  The  peripheral 
anemia  present  in  shock  is  the  result  of  accumulation  of  blood  in 
the  large  internal  vessels.  Besides  concussion,  thermal,  chemic, 
and  toxic  agents  are  known  to  produce  shock. 

G.  W.  Crile's  experiments  on  dogs  did  not  correspond  in 
their  results  with  those  of  Goltz.  In  my  presence  he  made 
several  demonstrations  by  opening  the  abdomen  of  the  anes- 
thetized animal,  either  beating  or  even  crushing  the  solar  plexus 
without  affecting  the  curve  made  by  the  kymograph,  while  a 
direct  blow  against  the  heart  always  resulted  in  a  sudden  depres- 
sion of  the  arterial  tension.  The  ether  anesthesia  may  do  much 
toward  the  prevention  of  shock.  Regnicr  and  Richet  produced 
some  of  the  symptoms  of  shock  in  rabbits  by  injecting  into  the 
peritoneal  cavity  from  five  to  twenty-five  grains  of  boiling  water  or 
one  grain  of  a  solution  of  chlorid  of  iron.  Death  of  the  animal 
ensued  in  from  twelve  to  twenty -four  hours,  and  was  always  pre- 
ceded by  a  marked  reduction  of  the  body -temperature.  If  the 
animals  were  brought  under  the  influence  of  chloral  before  the  ex- 
periment, life  was  prolf)nged,  a  consequence  which  thc\'  attributed 
to  a  diminution  of  the  excitabihty  of  the  spinal  cord,  due  to  the 
action  of  the  chloral.  Strong  electric  irritation  of  the  peritoneum 
and  intestines  continued  for  an  hour  did  not  produce  shock,  nor 
did  it  affect  the  temperature.      Iioi.se  does  not  believe  in  the  theory 


32  TRAUMATIC    SHOCK. 

that  shock  results  from  vasomotor  paralysis.  He  explains  shock 
by  assuming  a  hyperirritation  of  the  entire  sympathetic  system, 
and,  as  a  result,  stimulation  of  the  vasomotors,  contraction  of  the 
arterioles,  and  a  spasmodic  action  of  the  heart. 

Gutsch's  experiments  on  rabbits  show  that  mechanical  irritation 
of  the  peritoneum  and  intestines  is  productive  of  shock.  He 
believes  that  the  terminal  nerve  filaments  subjected  to  mechanical 
insults  cause  a  reflex  paralysis  through  the  splanchnic  nerves,  pro- 
ducing depression  of  the  nervous  centers.  Loss  of  heat  during 
abdominal  operations,  advanced  as  a  potent  and  common  cause  of 
shock  by  Wegner,  he  regards  as  only  one  of  the  many  causes  of 
shock.  He  found  in  rabbits  that  firm  compression  of  a  segment 
of  intestinal  coils  reduced  the  frequency  of  the  pulse  from  i68  to 
1 20,  and  on  another  occasion  from  162  to  108,  and  after  temporary 
increase  in  its  volume  it  became  small  and  feeble.  In  the  frog, 
handling  of  the  stomach  and  intestines  caused  reflex  paralysis  of 
the  heart  in  from  three  to  six  seconds. 

Bezold  and  Bever  found  that  section  of  the  splanchnic  nerve 
was  followed  by  accumulation  of  blood  in  the  paralyzed  abdominal 
vessels,  more  especially  the  veins,  while  the  vessels  not  damaged 
by  the  nerve  section  were  found  to  contain  a  comparatively  small 
quantity  of  blood.  The  other  nerves  of  the  blood-vessels  appear 
to  exercise  but  little  influence  in  regulating  the  circulation.  It 
seems,  then,  that  in  shock  the  reflex  influence  centers  principally 
on  the  splanchnic  nerve.  Reflex  paralysis  caused  by  trauma 
has  been  exhaustively  investigated  on  the  basis  of  large  clinical 
material  by  Weir  Mitchell,  Morehouse,  and  Keen.  Crushing  inju- 
ries of  the  extremities,  caused  by  railway  accidents  and  machineiy, 
furnish  the  largest  percentage  of  grave  cases  of  shock.  Concus- 
sion and  contusion  of  the  thorax,  abdomen,  and  testicles  and  frac- 
tures, dislocations,  and  contusions  of  fingers  are  injuries  that  are 
always  followed  by  more  or  less  shock.  Unnecessaiy  severe 
handling  of  the  ovaries  during  an  abdominal  operation  is  occasion- 
ally followed  by  severe  shock  (Goodell).  Fatal  shock  has  been 
observed  in  cases  of  severe  contusion  of  the  testicle  (Fischer, 
Schlesier).  Intestinal  perforation,  pathologic  and  traumatic,  not 
infrequently  gives  rise  to  severe  shock.  In  some  cases  of  acute 
intestinal  strangulation  symptoms  of  shock  set  in,  and  unless  the 
obstruction  is  relieved  promptly,  may  result  in  death.  The  pulse 
is  feeble  and  rapid  ;  the  surface  cold  and  cyanotic.  The  shock  in 
such  cases  appears  to  be  caused  by  the  intense  effect  of  the  intes- 
tinal irritation  on  the  splanchnic  nerve,  causing  shock  in  the  same 
manner  as  Goltz's  experiments. 

The  shock  is  not  always  proportionate  to  the  severity  of  the 
injuiy.  Comparatively  slight  injuries  in  persons  whose  nervous 
system  is  predisposed  to  shock  may  give  rise  to  dangerous  symp- 
toms, and  grave  injuries  not  infrequently  are  attended  by  a  mild 
degree  of  shock.     As  a  rule,  gunshot,  punctured,  stab,  and  incised 


ETIOLOGY. 


33 


wounds  do  not  produce  shock  to  the  same  extent  as  lacerated  and 
contused  wounds.  Crushing  injuries  involving  large  nerve-trunks 
are  known  to  give  rise  to  the  severest  form  of  shock.  The  old- 
fashioned  round  and  conic  lead  bullets  produced  more  severe 
shock  than  the  small-caliber  jacketed  bullet.  During  the  Greco- 
Turkish  war  and  the  late  Spanish-American  war  it  was  repeatedly- 
observed  that  grave  injuries  inflicted  by  the  small-caliber  bullet 
very  often  were  unattended  by  any  very  severe  general  shock. 
The  absence  of  severe  shock  was  particularly  noticeable  in  many 
cases  of  penetrating  wounds  of  the  chest,  abdomen,  and  large 
joints.  Wounds  of  the  lower  extremities  produce  greater  shock 
than  .similar  wounds  of  the  upper  extremities,  and,  as  a  rule,  the 
shock  is  greater  the  nearer  the  injury  is  to  the  trunk,  (nithrie 
cites  two  instances  in  which  the  intensity  of  the  shock  was  out  of 
all  proportion  to  the  palpable  damage  caused  by  the  bullet,  and 
led  to  the  suspicion  of  additional  injuries,  which  could  not  be 
recognized  at  the  time.  In  both  cases  the  autopsy  verified  the  sus- 
picion. In  one  case  the  injur}'  was  very  severe,  but  shock  was 
almost  entirely  absent.  "  A  soldier  at  Talavera  was  struck  in  the 
head  by  a  twelve-pound  shot,  which  drove  some  bone  into,  and 
some  brain  out  of,  his  head  ;  he  was  walking  about,  complaining 
but  little,  immediately  after  the  accident,  although  he  died  subse- 
quently." Shells  or  grape-shot  are  especiall}'  likely  to  produce 
severe  shock,  although  many  exceptions  occur.  During  the  battle 
before  Santiago  a  sergeant  of  the  regular  army  was  struck  by  a 
shrapnel  from  a  bursting  shell.  At  the  moment  he  was  injured  he 
believed  that  the  shell  hit  his  right  hip  before  it  exploded  some  dis- 
tance from  him.  A  few  moments  later  he  noticed  a  swelling  about 
the  size  of  a  child's  fist  above  the  trochanter.  He  kept  on  firing 
and  did  active  duty  during  the  whole  campaign.  Five  weeks  later 
an  abscess  developed  in  that  locality  and  ruptured  spontaneously. 
In  the  surgical  wards  of  Montauk  I  removed,  a  few  days  later,  a 
round  lead  ball  the  size  of  a  hazelnut  from  near  the  ilium,  in  the 
gluteal  region.  This  somewhat  severe  injury  not  only  failed  to 
produce  any  shock,  but  did  not  even  incapacitate  the  man  from 
doing  his  share  in  finishing  the  fight  and  the  campaign.  The  rule, 
the  larger  the  shot,  the  greater  the  shock,  has  also  its  exceptions. 
Pirogofif  removed  a  six-pound  cannon-ball  from  the  thigh  of  a 
soldier,  who  walked  a  few  steps  although  the  femur  was  fractured, 
and  found  him  suffering  but  little  from  shock.  Large  missiles  pro- 
duce shock  in  passing  clo.se  by  the  body  without  touching  it. 
Many  authenticated  cases  of  this  kind  are  on  record.  Pirogoff 
saw  a  soldier  who  was  killed  in  this  manner.  A  heavy  bomb 
pa.s.sed  in  close  proximity,  and  he  fell  unconscious  and  soon  died. 
A  careful  examination  fiiled  to  detect  any  evidences  of  injury. 
Postmortem  negative  :  brain  congested  but  nf)t  apoplectic. 

The  danger  of  shock  from  operations  has  been  greatly  dimin- 
ished by  the  use  of  anesthetics.      Although   operations  were   pcr- 
3 


34  TRAUMATIC    SHOCK. 

formed  more  rapidly  before  anesthetics  were  employed  than  they 
are  now,  shock  was  a  much  more  common  and  severe  complication 
than  it  is  at  present.  Pirogoff  lost  two  cases  of  amputation  of  the 
thigh  on  the  table  from  shock  before  he  used  anesthetics.  The 
fatal  moment  came  in  both  cases  at  the  time  the  bone  was  severed 
with  the  saw.  Death  was  preceded  by  rigidity  of  the  limbs,  deadly 
pallor  of  the  face,  dilated  pupils,  and  a  staring  look  of  the  eyes. 
While  anesthesia  has  greatly  diminished  the  danger  of  shock  from 
operations,  we  have  reason  to  believe  that  many  of  the  deaths 
which  have  occurred  on  the  table  since  anesthetics  have  been 
almost  universally  employed,  and  which  have  been  attributed  to 
their  use,  have  resulted  from  shock. 

Symptoms. — One  of  the  characteristic  clinical  features  of  shock 
consists  in  the  appearance  of  the  maximum  symptoms  almost  in- 
stantaneously after  the  infliction  of  the  injury,  which  distinguishes 
it  from  all  Avound  complications  that  otherwise  closely  resemble 
shock.  The  clinical  picture  is  complete  from  the  very  moment  the 
symptoms  of  shock  set  in.  In  marked  shock  the  patient  is  abso- 
lutely helpless  and  takes  no  notice  of  what  is  going  on  around 
him  ;  he  does  not  realize  the  gravity  of  his  condition  ;  the  face  is 
pale  and  apathetic  ;  the  skin  of  the  forehead  is  thrown  into  folds  ; 
the  nostrils  are  dilated,  and  a  staring  look  into  the  distance  at  once 
attracts  attention.  The  eyes  are  sunken  and  the  eyelids  half  closed, 
giving  to  the  eyes  a  meaningless,  staring  expression.  The  pupils 
are  dilated  and  respond  sluggishly  to  light.  The  skin  and  visible 
mucous  membranes  are  pale,  and  hands  and  lips  are  slightly  cyan- 
otic. The  surface  is  cold  and  bathed  with  a  clammy  perspiration, 
which  is  especially  marked  on  the  forehead  and  eyelids.  The  gen- 
eral sensibility  is  markedly  diminished.  Although  severely  in- 
jured, the  patient  can  be  examined  and  moved,  often  without  a  word 
of  complaint.  The  patient  makes  efforts  to  move  the  limbs  only 
on  urgent  and  repeated  requests,  and  the  movements  are  sluggish 
and  limited.  As  a  rule,  the  sphincters  remain  intact.  The  scanty 
urine  removed  from  the  bladder  by  the  use  of  the  catheter  presents 
nothing  abnormal.  The  pulse  is  almost  imperceptible,  small, 
thread-like,  and  often  irregular  or  intermittent.  The  arteries  are 
small  and  lack  normal  resistance.  Occasionally  the  pulse  is  re- 
duced in  frequency  to  fifty  or  even  fewer  beats  a  minute.  The 
same  slowness  of  the  pulse  can  be  artificially  produced  in  animals 
by  irritation  of  the  cut  ends  of  the  splanchnic  nerve.  In  such 
cases  the  irritation  of  the  splanchnic  is  transmitted  to  the  pneumo- 
gastric,  or  some  other  center  inhibiting  the  action  of  the  heart 
(Bernstein).  A  similar  irritation  may  be  transmitted  to  the  center 
of  respiration.  The  mental  faculties  are  not  impaired.  The  patient 
responds  to  questions  slowly  but  rationally,  in  a  feeble  and  often 
somewhat  husky  voice.  Wounds  can  be  examined  without  causing 
any  pain,  he  making  complaint  only  when  some  large  exposed 
nerve-trunks  are  touched.     The  patient  often  complains  of  a  feel- 


SYMPTOMS. 


35 


ing  of  chilliness,  a  sense  of  fainting,  and  prickling  and  numbness 
of  the  extremities.  The  respirations  are  irregular,  sometimes  deep 
and  sighing  ;  at  other  times  long  and  deep  inspirations  alternate 
with  very  superficial,  frequent,  hardly  perceptible  respiratory  move- 
ments. The  special  senses  remain  intact.  Nausea,  vomitin^-,  and 
singultus  are  prominent  symptoms. 

The  surface  temperature  is  subnormal,  as  is  ascertained  by  touch 
and  verified  by  the  use  of  the  thermometer.  During  the  revolution 
in  Paris,  after  the  Franco-Prussian  war,  Redard  made  the  first  reliable 
thermometric  observations  in  cases  of  shock.  He  found  the  general 
temperature  subnormal  in  all  the  cases  examined — fift\'  in  number. 
He  ascertained  that  the  reduction  in  body-temperature  corresponded 
with  the  size  of  the  bullet — that  is,  the  larger  the  missile,  the  greater 
the  shock  and  the  lower  the  temperature.  About  the  same  time 
Demarquay  made  similar  observations  and  came  to  the  same  con- 
clusions. During  the  months  of  March  and  April  he  examined 
thirty-eight  cases  in  the  hospitals  of  Paris,  and  alwa^^s  found  the 
temperature  subnormal.  Like  Redard,  he  found  a  similar  reduction 
of  temperature  in  extensive  binms.  The  .symptoms  enumerated  are 
associated  with  shock,  but  they  are  modified  by  the  temperament 
of  the  injured  persons,  the  environments,  and  the  degree  of  shock. 
While  the  mind  is  usually  clear,  in  some  cases  we  observe  incoher- 
ence of  speech  and  thought.  Shock  so  changes  the  general  appear- 
ance of  the  patient  that  it  is  often  difficult  to  recognize  him. 

Some  writers  continue  to  describe  a  form  of  shock  characterized 
by  excitement,  but  it  is  questionable  if  such  a  variety  of  shock  ever 
occurs  as  a  primary  complication  of  injuries  ;  it  is  more  probable 
that  it  follows  the  torpid  form  and  constitutes  the  stage  of  reaction 
in  certain  persons  who  are  the  subjects  of  an  excitable  nervous  tem- 
perament. It  is  known  as  cretliic  shock,  and  was  described  by 
Travers  as  prostration  with  excitement. 

In  this  form  or  .stage  of  shock  the  expression  of  the  face  indi- 
cates indescribable  fear  and  distress.  The  patient  is  restless  and 
tosses  about  wildly,  moans  and  cries  and  complains  of  difficulty 
in  breathing  and  of  a  sense  of  impending  death.  He  can  not  be 
consoled,  refuses  to  be  comforted,  and  acts  like  an  insane  person. 
The  mind  is  clear,  but  is  occupied  largely  by  the  fearful  suffering. 
The  visible  mucous  membranes  are  pale  ;  the  face,  on  the  other 
hand,  is  flushed,  the  forehead  hot,  the  eyes  sunken,  but  unusually 
brilliant,  the  pupils  contracted.  The  extremities  are  cold  and 
numb,  but  not  to  the  .same  extent  as  during  the  torpid  stage. 
Thirst  is  a  distressing  symptom  and  is  difficult  to  satisfy,  as  fluids 
administered  arc  ejected  as  soon  as  they  reach  the  stomach.  All 
movements  are  made  hastily  and  in  a  nervous  manner,  attended  by 
trembling.  I'"ibrillary  contractions,  especially  of  the  muscles  of  the 
face,  arc  frequently  ob.served.  The  pulse  is  small,  frequent,  almost 
imperceptible.  The  resi)irations  are  rapid  and  superficial.  I'ischcr 
claims  that  a  patient  recovering  from  torpid  shock  may  gradually 
pass  into  the  crethic  variety,  and  vice  versa. 


36  TRAUMATIC    SHOCK. 

Diagnosis. — In  pronounced  shock  it  is  usually  not  difficult  to 
make  a  diagnosis  if  the  patient  is  seen  soon  after  the  injury.  The 
symptoms  are  characteristic  and  can  not  be  mistaken  in  such  cases. 
Occasionally,  however,  it  is  difficult  to  make  a  differential  diagnosis 
between  shock  and  syncope  or  cerebral  concussion,  and  as  the 
treatment  must  depend  upon  a  correct  and  early  diagnosis,  the 
surgeon  must  study  the  symptoms  both  individually  and  collect- 
ively to  enable  him  to  make  a  correct  diagnosis. 

Cerebral  concussion  is  closely  allied  to  shock,  but  can  be  dis- 
tinguished from  it  by  the  unconsciousness  of  the  patient,  always 
present,  and  by  the  slow,  regular,  full  pulse.  The  part  injured  and 
the  nature  of  the  injury  will  also  aid  in  making  a  differential  diag- 
nosis between  these  two  conditions. 

It  is  more  difficult  to  differentiate  between  shock  and  syncope. 
They  differ  in  degree  and  duration  more  than  in  kind,  says  Travers. 
Syncope  is  caused  by  strong  mental  impressions,  violent  physical 
exercise,  loss  of  blood,  pain,  etc.,  while  shock  is  produced  by  trauma, 
independently  of  the  effects  of  pain  and  loss  of  blood.  Syncope 
is  attended  by  at  least  momentary  loss  of  consciousness,  and  it  is  a 
much  more  acute  and  evanescent  condition  than  shock. 

Shock  has  frequently  been  mistaken  for  hemorrhage  and  hemor- 
rhage for  shock.  These  two  wound  complications  are  most  liable 
to  be  confounded  with  each  other  in  practice,  as  many  of  the  symp- 
toms are  common  to  both  of  them.  In  making  the  differential 
diagnosis  it  is  important  t-o  study  the  nature  of  the  injury  and  to 
make  the  necessary  examination  to  detect  the  presence  and  location 
of  occult  hemorrhage.  In  shock  the  maximum  symptoms  of  the 
full  clinical  picture  present  themselves  immediately  after  the  receipt 
of  the  injury.  In  hemorrhage  the  symptoms  increase  in  intensity 
progressively,  and  their  severity. bears  some  relation  to  the  amount 
of  blood  lost.  Convulsions  usually  precede  death  from  hemor- 
rhage, while  they  are  absent  in  fatal  shock.  The  most  complicated 
cases  from  a  diagnostic  standpoint  are  those  in  which  shock  and 
hemorrhage  take  part  in  the  production  of  prostration.  If  the 
symptoms  of  shock  present  themselves  immediately  after  the  injury, 
as  they  always  do,  and  after  the  patient  rallies  again  increase  in 
severity,  the  probability  of  the  existence  of  hemorrhage  is  great. 
The  same  suspicion  must  be  entertained  if  the  temperature  continues 
to  fall  after  the  symptoms  of  shock  are  fully  developed. 

Prognosis. — In  fatal  cases  of  shock  death  ensues  in  from  a 
few  minutes  to  several  hours.  If  the  symptoms  of  shock  continue 
for  more  than  six  hours,  it  is  very  probable  that  hemorrhage  or 
serious  visceral  lesions  are  present,  and  that  the  continuance  of  the 
prostration  is  due  to  either  or  both  of  them.  There  are  certain 
symptoms  in  grave  cases  of  shock  that  may  be  relied  upon  in  pre- 
dicting a  fatal  termination.  A  very  low  temperature  is  such  an 
indication.  Basing  his  conclusions  on  an  extensive  clinical  experi- 
ence, Redard  made  the  statement  that  "  the  wounded  whose  tem- 


PATHOLOGY. 


37 


perature  falls  below  96.8°  F.  usually  die."  A  similar  result  may 
be  expected  if  reaction  does  not  set  in  under  appropriate  treatment 
in  the  course  of  a  few  hours. 

Loss  of  power  in  swallowing  is  considered  a  particularly  un- 
favorable symptom,  indicating,  according  to  Manscll  Moullin,  an 
inhibition  of  the  glossopharyngeal  center.  Uncomplicated  shock 
is  followed  b}-  reaction  within  eighteen  hours,  and  if  this  fails  to 
take  place  during  this  time,  it  never  occurs  (Cheever).  In  pro- 
longed shock  it  becomes  necessary  for  the  surgeon  to  examine  care- 
fully for  complications,  more  especially  for  hemorrhage  and  visceral 
lesions,  to  guide  him  in  formulating  the  prognosis  and  in  adopting 
and  applying  the  appropriate  therapeutic  measures. 

Pathology. — In  death  from  shock  the  postmortem  findings, 
aside  from  the  injury  which  produced  it  and  the  evidences  of  great 
vascular  disturbances,  are  negative.  The  peripheral  vessels  are 
small  and  contain  but  little  blood,  while  the  large  abdominal  ves- 
sels, arteries,  and  veins  are  found  constantly  distended  with  blood. 
In  a  horse  that  died  from  shock  caused  by  a  fall  Grebe  found  an 
enormous  plethora  of  the  abdominal  organs  which  had  given  rise 
to  hemorrhagic  infarcts  in  the  intestinal  coats  and  hemorrhages  into 
the  stomach  and  intestines.  Shock  causes  cerebral  anemia,  but  the 
sinuses  and  veins  are  often  found  engorged  with  blood.  In  death 
from  shock  caused  by  a  blow  against  the  epigastrium  autop.sy 
revealed  distention  of  the  superior  longitudinal  sinus  and  a  moderate 
venous  hyperemia  of  the  brain  and  spinal  cord.  In  case  of  recov- 
ery from  shock  it  is  not  unusual  to  find  secondary  lesions  caused 
by  the  intense  vascular  disturbances  which  are  constant  in  shock, 
and  which  are  proportionate  to  the  severity  of  the  shock.  Keen, 
Mitchell,  and  Morehouse  reported  seven  cases  of  paralysis  due  to 
injuries  received  in  the  Civil  War,  in  each  of  which  the  paralyzed 
part  was  distant  from  the  injured  limb  and  not  in  direct  venous 
communication.  Similar  cases  have  been  described  by  Barlow, 
Bencdikt,  Rumke,  and  Schwan.  Leyden  is  of  the  opinion  that  in 
such  cases  the  paralysis  is  a  neurotic  complication — that  is,  the 
extension  of  infection  from  the  seat  of  injury  to  the  spinal  cord 
and  its  meninges  or  an  indirect  extension  by  metastasis.  There 
is,  however,  good  ground  for  the  belief  that  paralytic  comjilica- 
tions  as  a  consequence  of  shock  occur  as  the  result  of  vascular 
disturbances  or  as  remote  manifestations  of  reflex  inhibitory  influ- 
ences. In  several  cases  of  pernicious  anemia  it  has  been  shown  by 
competent  ob.servcrs  that  a  direct  etiologic  connection  could  be 
traced  between  shock  and  the  development  of  the  blood  di.seasc 
soon  after  the  injury  was  sustained.  In  a  number  of  adults  suffering 
from  shock  following  a  fall  from  a  height  albumin  an<l  casts  were 
detected  in  the  urine.  The  urine  cleared  up  after  from  two  to  four 
days.  In  .several  cases  autopsy  showed  the  lesion  of  acute  paren- 
chymatous nephritis.  As  none  of  the  ca.scs  suffered  from  head 
injury,  the  mfluence  of  a  cerei^ra!  reflex  could  not  be  surmised,  and 


38  TRAUMATIC    SHOCK. 

therefore  a  direct  reaction  of  the  force  upon  the  kidney  structure 
or  intense  vascular  engorgement,  must  be  assumed  as  the  imme- 
diate cause  of  the  renal  complication.  The  results  of  the  experi- 
ments of  Galeozzi  to  show  the  existence  of  a  direct  etiologic  con- 
nection between  shock  and  septic  infection  proved  negative.  Never- 
theless, it  can  not  be  denied  that  the  serious  vascular  disturbances 
which  take  place  in  shock  may  act  as  a  potent  determining  cause 
in  the  subsequent  development  of  the  infective  process,  by  furnish- 
ing a  locus  ininoris  I'esistenticB  for  the  localization,  growth,  and  dis- 
semination of  pyogenic  microbes. 

Treatment. — In  the  treatment  of  shock  it  is  as  important  to 
know  what  not  to  do  as  what  to  do.  As  shock  is  frequently  the 
result  of  injuries  that  demand  operative  treatment,  the  question 
necessarily  arises  as  to  what  is  the  most  opportune  time  for  the  per- 
formance of  the  operation.  With  few  exceptions  writers  on  surgery 
condemn  operation  during  shock.  Advocates  who  were  in  the  past 
in  favor  of  primary  operation  during  shock  were  Pare,  Wiseman, 
Larrey,  and  McLeod.  Larrey  says  :  "  I  have  lost  a  great  number 
of  soldiers,  because,  although  operated  upon  within  the  first  twenty- 
four  hours,  yet  the  operation  had  been  performed  too  late.  It  is 
then  demonstrated  that  the  commotion,  far  from  being  a  contra- 
indication to  primitive  amputation,  ought  to  decide  the  surgeon  in 
its  favor.  The  effects  of  commotion,  far  from  being  aggravated, 
diminish  and  disappear  insensibly  after  the  operation."  Duboys, 
who  served  in  America  during  the  war  of  the  Revolution,  states 
that  "American  surgeons  amputated  at  once  and  lost  but  few,  but 
that  the  French  delayed  and  lost  many."  It  must  not  be  forgotten 
that  these  surgeons  came  to  their  conclusions  at  a  time  when 
anesthetics  were  not  in  use.  Anesthesia  adds  to  the  danger  of  the 
operation  in  such  cases.  Pirogoff  is  not  in  favor  of  operations 
during  shock,  and  advises  that  in  case  an  operation  is  urgently 
demanded  it  should  always  be  performed  without  anesthesia.  At 
the  present  time  the  consensus  of  opinion  of  almost  all  operators 
of  experience  is  opposed  to  operations  that  can  be  postponed 
until  the  patient  has  rallied  from  the  immediate  effects  of  the  injury. 
The  severing  of  a  limb  nearly  detached,  the  ligation  of  blood- 
vessels, and  other  emergency  work  that  can  be  done  in  a  few 
moments  without  an  anesthetic  would  not  add  to  the  existing 
shock  and  would  be  considered  good  surgery. 

In  performing  important  operations,  and  especially  operations 
that  are  apt  to  be  prolonged  and  which  involve  important  organs, 
the  surgeon  should  resort  to  proper  prophylactic  measures  with  a 
view  of  diminishing  the  liability  to  shock.  As  long  ago  as  1880 
Stephen  Smith  advocated  alcohol  for  this  purpose.  He  adminis- 
tered whisky  every  hour,  in  doses  large  enough  to  produce  slight 
intoxication  before  the  anesthetic  was  administered  and  the  opera- 
tion performed.  He  found  that  patients  thus  prepared  could  be 
anesthetized  without  much  excitement  and  were  less  liable  to  suffer 


TREATMENT. 


39 


from  shock.  I  have  been  in  the  habit  for  years  of  preparinj^ 
patients  for  grave  operations  by  administering  two  ounces  of 
whisky  by  the  stomach  or  rectum  an  hour  before  the  time  set  for 
the  operation,  and  by  injecting  -^  of  a  grain  of  strychnin  hypo- 
dermically  a  few  minutes  before  anesthetizing  the  patient.  I  am 
satisfied  that  these  prophylactic  measures  have  been  of  great  vakie 
in  minimizing  the  danger  from  the  anesthesia  and  the  shock  incident 
to  the  operation.  It  is  hkewise  important  to  prevent  loss  of  licat 
and  to  favor  peripheral  circulation  by  enveloping  the  body  and 
limbs  in  warm  blankets  during  the  operation.  The  experiments  of 
Dudley  P.  Allen  have  demonstrated  sufficiently  the  value  and 
importance  of  this  precaution  against  shock. 

The  treatment  of  shock  is  purely  s\-mptomatic.  Rest  in  the 
recumbent  position,  the  external  application  of  chy  heat  to  the 
body  and  extremities,  the  inhalation  of  nitrite  of  amyl,  and  the  ad- 
ministration of  stimulants,  such  as  alcohol,  camphor,  coffee,  and 
tea,  constitute  the  usual  routine  treatment  of  shock.  The  danger 
of  causing  burns  must  not  be  lost  sight  of  in  applying  heat.  Hot 
bottles  and  bricks,  frequently  employed  for  this  purpose,  must  be 
wrapped  in  flannel  to  guard  against  so  undesirable  a  complication. 
As  alcoholic  stimulants,  hot  red  wine  and  rum,  whisky,  or  brandy 
punch  deserve  tiie  preference.  If  spirits  are  used,  an  ounce  should 
be  given  ever)^  fifteen  to  thirty  minutes  until  reaction  is  established. 
In  the  gravest  cases  the  remedy  that  will  act  most  promptly  is 
nitrite  of  amyl  by  inhalation.  This  drug  is  a  powerful  heart  and 
vascular  stimulant,  and  will  produce  an  impression  in  a  few  moments, 
thus  bridging  over  the  most  critical  period  for  the  administration  of 
stimulants  with  a  more  lasting  effect.  Copious  rectal  enemata  of 
hot  normal  salt  solution  are  always  valuable  and  should  never  be 
neglected  in  the  treatment  of  pronounced  shock.  Subcutaneous  or 
intravenous  infusions  of  the  .same  solution  have  had  an  extensive 
trial  in  the  treatment  of  shock,  and  with  the  most  encouraging  re- 
sults. Crilc  has  experimented  with  the  blood  pressure  in  shock 
produced  by  manipulation  and  irritation  of  tiie  various  tissues  and 
organs  of  the  body,  and  favors  the  treatment  by  intravenous  injec- 
tions of  warm  saline  sf)lutions,  along  with  a  dilute  solution  of 
strychnin  slowly  injected  into  the  rubber  tube  of  the  infusion  appa- 
ratus. Opium  is  contraindicated  in  the  treatment  of  uncomplicated 
shock.  If  the  patient  can  not  swallow,  or  if  nausea  and  vomiting 
interfere  with  the  administration  of  stimulants,  resort  to  subcuta- 
neous and  rectal  injections  becomes  a  necessity.  Groeningen  rec- 
ommends <ligitalis  as  a  vascular  stimulant. 

In  the  erethistic  stage  of  shock  opiates  are  indicated,  but  their  u.sc 
requires  cautif)n.  Subcutaneous  injections  of  sterilized  camphorated 
oil  can  be  relied  upon  as  a  valuable  cardiac  stimulant.  TJiree  or 
four  hypodermic  syringefuls  administered  every  fifteen  minutes  until 
indications  of  reaction  set  in  is  the  rule  to  be  followed  in  the  use  of 
this  drug.      Electric  stimulation  of  the  phrenic  ikmvcs  and  arlincial 


40  GENERAL    ANESTHESIA. 

respiration  are  indicated  in  desperate  cases.  Goltz  found  that  ab- 
dominal tapotement  in  animals  is  less  dangerous  if  the  peripheral 
nerves  of  the  extremities  are  subjected  to  intense  irritation  ;  hence 
the  value  of  sinapisms  and  electricity  as  therapeutic  agents.  In- 
halation of  oxygen  recommends  itself  as  a  rational  remedy  when 
life  is  threatened  by  shock,  particularly  in  cases  in  which  the  res- 
piratory function  is  threatened.  In  shock  absorption  of  drugs 
administered  by  the  stomach  or  rectum,  or  even  if  injected  into  the 
tissues,  is  always  slow,  as  has  been  shown  by  the  experiments  of 
Rogers  and  Brown-Sequard  ;  hence  care  is  necessary  to  guard 
against  cumulative  reaction  during  the  recovery  of  the  patient. 
The  experiments  just  alluded  to  seem  to  indicate  that  absorption  is 
retarded,  owing  to  a  diminished  or  suspended  interchange  between 
the  blood  and  the  tissues.  The  therapeutic  value  of  strychnin  in 
the  treatment  of  shock  is  doubtful.  Experiments  on  animals  have 
demonstrated  that  this  drug  can  not  be  relied  upon  in  shock. 
Contejean  explains  this  by  the  fact  that  in  animals  in  a  state  of 
shock  artificially  produced  the  spinal  cord  is  seen  to  be  anemic — 
not  supplied  with  sufficient  blood  to  convey  the  remedy  to  this 
center  of  innervation.  Gscheidlen  has  shown  that  the  extract  of 
the  Calabar  bean  is  a  potent  stimulant  of  the  splanchnic  nerves. 
Under  its  influence  the  intestinal  peristalsis  is  diminished,  as  well  as 
the  abdominal  plethora.  Further  experiments  are  necessary  to 
establish  the  therapeutic  reliability  of  this  powerful  remedy  in  the 
treatment  of  traumatic  shock. 


CHAPTER   III. 

GENERAL  ANESTHESIA* 

General  anesthesia  is  justifiable  during  all  major  operations, 
and  in  facilitating  painful  and  prolonged  examinations  for  diagnostic 
purposes.  There  can  be  but  little  doubt  that  this,  one  of  the  greatest 
blessings  of  modern  surgery,  has  frequently  been  employed  unneces- 
sarily. In  the  performance  of  minor  operations  of  short  duration 
the  risks  incident  to  the  administration  of  a  general  anesthetic  are 
frequently  not  balanced  by  the  benefits  to  be  derived  from  it.  It  is 
the  abuse,  and  not  the  legitimate  and  proper  use,  of  general  anestJietics 
that  is  open  to  criticism  at  the  present  time.  Some  surgeons  seldom 
perform  an  operation,  however  insignificant  it  may  be,  Avithout 
placing  the  patient  under  the  influence  of  a  general  anesthetic  ; 
while  others  frequently  perform  operations  of  short  duration  without 
it.  The  proper  course  to  pursue  is  to  choose  the  happy  mean 
between  these  two  extremes. 

Local  anesthetics  have  narrowed  to  a  considerable  extent  the 


STATISTICS.  41 

indications  for  the  emplo}'ment  of  general  anesthetics.  Most  of  the 
operations  on  the  eye  and  minor  operations  in  other  parts  of  the 
body  that  can  be  completed  in  a  few  minutes  no  longer  warrant 
general  anesthesia.  Although  the  mortality  from  general  anes- 
thetics is  small, — probably  less  than  i  in  1000, — the  fact  can  not 
be  ignored  that  every  full  anesthesia  brings  the  patient  dangerously 
near  the  dividing-line  between  life  and  death  ;  in  other  words,  the 
life  of  every  anesthetized  patient  is  always  in  danger.  It  must  also 
not  be  forgotten  that  many  deaths  from  general  anesthetics  have 
occurred  during  the  performance  of  insignificant  operations,  and  it 
is  when  accidents  of  this  kind  occur  under  such  circumstances  that 
the  remorse  of  the  operator  is  greatest  and  the  reproach  of  the 
relatives  of  the  victim  most  bitter.  I  have  personal  knowledge  of 
a  case  of  resection  of  the  knee-joint  successfully  performed,  by  a 
very  able  and  painstaking  surgeon,  the  patient,  nevertheless,  dying 
from  the  effects  of  the  anesthetic,  administered  for  the  second  time 
when  the  surgeon  wished  to  remove  the  sutures. 

Gurlt's  statistics  up  to  1893,  based  on  157,815  war  cases,  show 
53  deaths,  or  one  in  2900.  Of  these  fatal  cases,  we  find  one  death 
from  chloroform  in  every  2899  cases  ;  chloroform  with  ether,  one 
in  41,181  ;  ethyl  bromid,  one  in  4588;  pental,  one  in  199.  No 
deaths  are  reported  from  ether  and  the  A.  C.  E.  mixture.  That 
these  statistics  are  reliable  no  one  would  dispute.  More  deaths 
undoubtedly  occur  from  the  use  of  anesthetics  than  we  find  re- 
ported in  the  current  medical  literature  or  through  personal  com- 
munications, to  say  nothing  of  the  many  deaths  caused  by  the  remote 
consequences  of  the  toxic  effects  of  the  anesthetics.  If  the  whole 
truth  were  known,  it  is  safe  to  say  that  at  least  one  death  occurs  in 
every  lOOO  cases  of  general  anesthesia,  either  in  consequence  of 
the  primary  or  the  secondary  toxic  effects  of  the  anesthetic.  One 
death  from  ether  occurred  in  my  own  practice. 

The  administration  of  a  general  anesthetic  is  comparatively  safe 
in  the  hands  of  the  expert ;  it  becomes  a  dangerous  zveapon  when 
left  to  the  inexperienced.  The  admini.stration  of  an  anesthetic  requires 
skill,  experience,  caution,  foresight,  and  prompt  and  efficient  action 
when  untoward  alarming  symptoms  appear.  ICvery  medical  student 
should  receive  careful  instruction  in  anesthetization,  and  should  be 
given  the  advantages  of  an  ample  practical  training,  under  the  super- 
vision of  a  competent  instructor,  before  his  graduation.  This  part 
of  his  in.struction  can  not  be  learned  from  text-books  and  lectures 
— it  must  be  obtained  by  actual  experience  in  the  ojjerating  room. 
(In  Rush  Medical  College  this  y)art  of  the  surgical  teaching  has 
been  placed  in  charge  of  a  special  instructor,  under  who.se  watchful 
care  and  .safe  guidance  each  member  of  the  graduating  class  is 
required  to  administer  ancstiietics  a  sufficient  number  of  times  to 
make  him  jjroficient  in  this  part  of  his  surgical  acquirements.) 

Very  few  physicians  are  safe  a7iesthetizers.    This  lack  of  familiarity 
with  a  mo.st  responsible  duty,  one  they  are  so  often  called  ujion  to 


42  GENERAL    ANESTHESIA. 

perform,  is  largely  due  to  the  imperfect,  fragmentary  instruction  of 
this  important  part  of  their  medical  education,  an  evil  that  can  not 
be  remedied  too  soon. 

Besides  inexperienced  anesthetizers,  adulteration  of  the  anes- 
thetics is  responsible  for  many  accidents.  The  anesthetic  must  be 
pure.  A  few  manufacturing  firms  have  earned  a  well-deserved  rep- 
utation in  producing  anesthetics  of  unquestionable  purity,  and  they 
deserve  the  patronage  of  the  profession.  Every  physician  sJioidd  be 
competent  to  detect  impurities  and  to  reject  all  preparations  that  do 
not  satisfy  his  tests.  In  eliminating  all  sources  of  danger,  it  also 
becomes  necessary  to  subject  all  patients  to  be  anesthetized  to  a 
thorough  physical  examination,  to  ascertain  their  physical  condition 
and  to  enable  the  physician  to  select  the  safest  anesthetic.  Visceral 
affections  of  the  blood-vessels,  heart,  lungs,  bronchial  tubes,  and 
especially  of  the  kidneys,  should  be  ascertained  by  a  careful  phy- 
sical examination  and  urine  tests.  Except  in  cases  in  which  delay 
would  be  dangerous,  the  condition  of  the  kidneys  should  always  be 
determined  by  an  examination  of  the  urine. 

The  selection  of  the  anesthetic  is  a  matter  of  great  importance. 
Ether  narcosis  is  preceded  and  attended  by  increased  intravascular 
tension  and  capillary  congestion,  more  especially  in  the  capillaries 
of  the  brain  and  bronchial  tubes.  Chloroform  is  a  decided  seda- 
tive, and  its  full  effect  is  characterized  by  a  marked  cerebral  anemia. 
It  is  not  good  practice  to  rely  on  one  anesthetic  in  all  cases.  The 
choice  of  the  anestlietic  shoidd  be  made  to  correspond  zvith  the  patient's 
physical  condition. 

Statistics  Jiave  proved  beyond  all  reasonable  doubt  that,  on  the 
whole,  chloroform  is  more  dangerous  than  ether.  In  our  country 
professional  and  popular  opinion  is  more  favorable  to  ether  than  to 
chloroform,  and  on  this  account,  if  for  no  other  reason,  it  has 
always  been  the  anesthetic  of  choice.  But  there  are  conditions 
that  would  render  the  use  of  ether  more  dangerous  than  chloroform. 
The  best  results  are  secured  by  keeping  in  mind  the  physiologic 
action  of  both  anesthetics,  and  on  this  ground  selecting  the  cases. 
(In  Rush  Medical  College  Clinic  every  case  is  carefully  examined 
before  deciding  upon  the  anesthetic.)  In  the  absence  of  contra- 
indications chloroform  is  used  in  all  operations  on  the  skull,  brain, 
stomach,  kidney,  air-passages,  and  lungs.  Chloroform  is  also 
always  used  in  patients  the  subjects  of  atheroma,  arteriosclerosis, 
or  affections  of  the  bronchial  tubes,  lungs,  and  kidneys.  I  have 
seen  so  many  cases  of  bronchitis,  pneumonia,  and  nephritis  from 
ether  that  I  have  learned  to  avoid  this  anesthetic  in  all  cases  of 
preexisting  disease  which  might  be  aggravated  by  the  irritating  and 
stimulating  effect  of  this  anesthetic.  In  prolonged  operations — 
that  is,  operations  requiring  more  than  an  hour — I  am  very  partial 
to  a  primary  chloroform  narcosis,  followed  by  ether.  This  mixed 
anesthesia  has  two  distinct  advantages,  in  that  the  patient  is  brought 
under  the  influence  of  the  anesthetic  quickly,  without  much  saliva- 


SAFETY.  43 

tion,  retching,  or  vomiting,  and  the  depressing  effect  of  chloroform 
is  avoided  b}'  substituting  ether  for  it  after  full  anesthesia  has  been 
reached.  Mixed  anesthetics  should  be  avoided,  sueJi  as  uiixtnres  of 
cJdorofonn  and  et/ier,  chlorofonn  and  alcohol,  and  the  A.  C.  E. 
mixture  of  Billroth,  as  in  the  event  of  the  appearance  of  nntozcard 
symptoms  the  aiiesthetizer  can  not  akvays  knozv  to  wJdcJi  of  the  constit- 
uents to  attribute  tJiem,  and  consequejitly  his  actions  are  Jiecessarily 
uncertain  a?ui  perhaps  contrary  to  ichat  should  be  done. 

In  bloody  operations  on  the  face  and  mouth,  as  in  operations  for 
harelip,  carcinoma  of  lips  and  face,  excision  of  the  maxdlcE  and 
tongue,  the  anesthesia  should  not  be  complete.  The  narcosis  is 
carried  to  the  stage  of  insensibility  so  far  as  pain  is  concerned, 
but  the  patient  should  remain  sufficiently  conscious  to  respond  to 
questions  and  to  cooperate  with  the  surgeon  in  clearing  the  mouth 
of  blood,  and  thus  prexent  more  effectually  its  entrance  into  the 
air- passages.  Since  I  have  adopted  this  course  I  have  had  no 
occasion  to  perform  preliminary  tracheotom\^  for  any  operation 
above  the  larynx.  The  usefulness  and  efficiency  of  such  a  "  talk- 
ing" partial  anesthesia  are  increased  by  administering,  half  an  hour 
before  anesthetization  is  commenced,  two  ounces  of  whisky  or 
brandy  in  a  little  sweetened  water,  and  in  very  nervous  patients,  ^ 
of  a  grain  of  morphin  is  given  subcutaneously  fifteen  minutes  later. 
Patients  thus  anesthetized  will  often  manifest  pain  and  remonstrate 
during  the  operation,  but  have  little  or  no  recollection  of  it  after 
consciousness  returns.  It  is  a  mistaken  idea  that  children  are 
more  immune  to  the  toxic  effect  of  chlorofonn  than  adults.  I  have 
seen  alarming  symptoms  attending  chloroform  narcosis  moi^e  fre- 
quently in  children  than  in  adults.  Age,  then,  should  con.stitute 
no  criterion  in  the  selection  of  the  anesthetic.  The  e.xperience  and 
reliability  of  the  ancsthetizer  must  be  taken  into  consideration  in 
making  the  final  choice  between  ether  and  chloroform.  lither  is 
safer  tJiaii  chloroform  in  the  hands  of  the  untrained  and  careless 
assistant.  It  is  a  great  source  of  comfort  to  the  operating  surgeon 
when  he  has  the  .sati.sfaction  of  knowing  that  the  anesthetic  is  being 
given  by  a  watchful,  conscientious,  experienced  physician,  who 
takes  no  interest  in  the  operation,  but  whose  whole  attention  is  ab- 
sorbed by  the  patient  whose  life  for  the  time  being  rests  in  his 
hands.  No  matter  how  competent  the  ancsthetizer  may  be,  the 
surgeon  should  never  lose  sight  of  his  patient,  no  matter  how  trying 
the  operation,  as  he  is  the  one,  after  all,  who  should  feel  that  he 
takes  the  place  of  his  patient  during  the  .stage  of  unconsciousness. 

In  emergency  surgery  the  administration  of  the  anesthetic  must 
often  be  intru.stcd  to  nonprofessional  a.s.si.stants,  and  it  is  in  such 
cases  that  the  surgeon  feels  most  keenly  his  responsibility  to  his 
patient  and  watches  with  unceasing  care  the  progress  of  the  anes- 
thesia. He  is  on  the  lookout  for  signs  of  danger,  and  when  they 
do  appear,  he  meets  them  in  person  at  the  j)roper  time  Under 
such  circumstances  ether  is  the  anesthetic  f)f  choice  unless  visceral 


44  GENERAL    ANESTHESIA. 

lesions  incompatible  with  its  safe  use  furnish  positive  contraindica- 
tions. Every  emergency  bag  should  contain  both  anesthetics,  as 
occasionally  in  persons  with  certain  idiosyncrasies  the  first  few 
inhalations  of  chloroform  sometimes  cause  alarming  symptoms,  and 
the  safety  of  the  patient  demands  a  change  to  ether.  In  other 
cases,  when  it  is  next  to  impossible  to  procure  full  anesthesia  with 
ether,  a  change  to  chloroform  produces,  in  a  short  time,  the  desired 
effect. 

Chloroform  Anesthesia. — It  is  under  this  heading  that  the 
pi-eparations  to  be  made  for  anesthesia,  and  the  accidents  met  and 
their  treatment,  will  be  discussed. 

Chloroform  was  introduced  as  an  anesthetic  by  Simpson,  in 
1847.  It  is  a  heavy,  colorless,  clear,  volatile  fluid,  with  the  chemic 
formula  CHCI3.  Its  odor  is  not  disagreeable,  and  when  inhaled 
the  vapor  is  absorbed  very  rapidly  by  the  mucous  membrane  of  the 
air-passages.  It  is  a  strong  poison,  which,  when  introduced  into 
the  circulation  by  inhalation  or  otherwise,  produces  a  paralytic 
effect  on  the  ganglia  cells  of  the  brain  and  spinal  cord,  and  in 
toxic  doses  results  in  arrest  of  respiration  and  of  heart  action.  The 
paralysis  appears  to  advance  in  the  brain  in  an  anteroposterior 
direction,  first  arresting  consciousness  and  terminating  in  suspension 
of  the  function  of  the  medulla  oblongata,  with  its  immediate  conse- 
quence, arrest  of  respiration.  It  was  formerly  believed  that  death 
from  chloroform  was  usually  due  to  paralysis  of  the  heart,  but  the 
results  of  the  investigations  of  the  Hyderabad  Commission,  as  well 
as  more  carefully  made  clinical  observations,  have  shown  that  the 
toxic  effect  of  chloroform  is  manifested  first  by  its  paralytic  effect  on 
the  center  of  respiration.  This  is  a  very  important  discovery,  as  it 
teaches  a  valuable  lesson  in  its  administration  as  an  anesthetic — 
that  is,  to  pay  more  attention  to  disturbances  of  respiration  than 
of  the  organs  of  circulation  as  incipient  manifestations  of  its  poisonous 
action.  So  long  as  the  fwictioris  of  the  respiratory  organs  are  not 
seriously  impaired  by  its  action,  no  serious  residts  are  to  be  apprehended. 
On  the  contrary,  any  serious  disturbances  of  respiratioji  are  a  sufficient 
warbling  for  the  exercise  of  extraordinary  care  to  ward  off  danger 
from  this  source.  Temporary  suspension  of  respiration  and  cyan- 
osis are  conditions  that  must  always  be  dreaded  and  that  call  for 
additional  care  in  the  further  use  of  the  anesthetic. 

As  has  been  mentioned  before,  chloroform,  to  be  safe,  must  be 
pure.  It  is  the  impure,  adulterated  article  that  is  most  liable  to 
give  rise  to  toxic  symptoms  and  death.  Chloroform  should  contain 
no  alcohol  and  no  ether,  no  methyl  combinations  (which  are  shown 
by  a  black  color  on  adding  concentrated  nitric  acid),  no  free  chlorin 
(shown  by  the  bleaching  effect),  no  acids  (exhibited  by  turning 
blue  litmus-paper  red).  The  odor  test  of  Heppe  consists  in  pouring 
a  few  drops  of  chloroform  on  Swedish  filter-paper  ;  if  a  sharp,  rancid 
odor  remains  after  evaporation,  it  is  proof  of  the  presence  of  im- 
purities. 


PREPARATIONS.  45 

One  great  objection  to  chloroform  as  an  anesthetic  at  night  in 
a  room  Hghted  by  gas  is  the  fact  that  decomposition  of  the  vapor 
results  in  the  production  of  a  \ery  irritating  gas,  which,  by  its 
action  on  the  mucous  membranes  of  the  air-passages,  causes  distress- 
ing cough  and  a  bronchial  irritation  that  may  remain  for  a  long 
time.  The  effect  of  this  gas  can  be  ax-oided  to  a  certain  extent  by 
opening  the  windows  and  filling  the  room  with  steam.  I  was  in- 
formed by  a  medical  officer  of  the  Civil  War  that  some  of  the  more 
alarming  symptoms  of  chloroform  narcosis — great  excitement  and 
cyanosis — can  be  avoided  by  adding  one  dram  (4  gm.)  of  nitrite  of 
am}-l  to  one  pound  of  chloroform.  This  mixture  was  used  very 
extensively  at  that  time,  with  the  most  satisfactor}-  results.  I 
have  used  the  mixture  ver}'  frequent!}-,  and  have  observed  that 
the  addition  of  nitrite  of  amyl  certainly  has  a  good  effect  on  the 
capillary  circulation,  cx'anosis  being  much  less  frequenth'  seen  than 
when  chloroform  alone  was  used.  At  the  same  time  the  depressing 
effect  of  the  chloroform  on  the  heart  was  noticeably  diminished. 

Preparations  for  Anesthesia. — In  emergency  work  anesthetics 
must  often  be  given  without  any  elaborate  preparations,  owing  to 
the  urgency  of  the  case.  When  time  permits,  everything  should 
be  done  to  make  ample  preparations  for  all  possible  emergencies. 
The  stomach  should  invariabh'  be  empt\-,  as  vomiting  is  likely  to 
be  provoked  by  the  anesthetic,  and  the  food  ejected  might  enter  the 
air-passages,  causing  immediate  death  from  asph}-xia  ;  or,  if  this 
danger  is  passed  over,  an  aspiration  pneumonia  is  a  more  remote 
complication.  If  the  anesthetic  has  to  be  given  on  a  full  stomach, 
the  patient  should  be  turned  on  one  side,  with  the  head  in  a 
dependent  position  during  the  act  of  vomiting,  so  as  to  favor  the 
ejection  of  the  food  from  the  mouth.  The  bowels  and  bladder 
should  be  evacuated,  the  former  by  cathartics  and  enema,  the  latter, 
if  need  be,  by  aseptic  catheterization.  All  unnecessary  clothing 
must  be  removed,  especially  such  as  would  interfere  with  the  free 
movements  of  the  chest  and  abdomen.  The  cavity  of  the  mouth 
must  be  inspected,  and  all  foreign  substances,  such  as  artificial 
teeth,  gum,  food,  chewing  tobacco,  etc.,  removed.  The  patient  is 
placed  on  the  operating  table,  with  the  head  on  the  same  le\'el  as 
the  body,  or  slightly  elevated  on  a  small  pillow,  or,  what  is  still 
better,  a  firm  compress.  Upon  a  small  stand  or  chair  at  the  head 
of  the  operating  table,  and  within  ea.sy  reach  of  the  anesthetizer, 
are  placed  all  articles  needed  during  narcosis — ether,  chloroform, 
hyjKjdermic  .syringe  charged  with  a  solution  of  -^-^  of  a  grain  of 
strychnin,  granules  of  digitalis,  y^^  of  a  grain,  capsules  of  nitrite 
of  amyl,  wash-basin,  tongue  forceps,  a  four-ounce  bottle  of  whisky 
or  brandy,  a  two-ounce  bottle  of  vinegar,  an  electric  battery,  a 
chloroform  mask,  an  ether  cone,  a  sponge  holder  armed  with  a  sea- 
sponge  or  small  gauze  compress,  and  a  number  of  towels  or  napkins. 

Everything  being  in  readiness  for  the  narcf)sis,  the  patient  is 
placed  on  the  table  in  the  recumbent  dorsal  position,  and  the  sur- 


46 


GENERAL    ANESTHESIA. 


face  of  the  body  not  exposed  during  the  operation  well  protected 
by  woolen  blankets,  so  as  to  prevent  unnecessary  and  perhaps  dan- 
gerous loss  of  body-heat  during  the  operation.  The  temperature 
of  the  room  should  not  be  lower  than  75°  F.,  and  not  higher  than 
85°  F.,  according  to  the  general  condition  of  the  patient,  the  na- 
ture and  probable  duration  of  the  operation.  The  skin  exposed  to 
the  caustic  action  of  chloroform  is  covered  with  oil,  vaselin,  butter, 
cream,  or  any  other  fatty  substance.  The  anesthetizer  takes  his 
place  at  the  head  of  the  table,  seated  on  a  chair  or  stool  of  conve- 
nient height.  Tlie  paticnf  s  mind  must  be  diverted  as  much  as  possible 
from  the  ordeal  before  him.  This  is  neither  the  time  nor  the  place  to 
talk  about  danger  or  death.  A  proper  understanding  in  regard  to  the 
probable  outcome  of  the  operation  must  have  been  reached  between 
surgeon  and  patient  ere  this.  TJiis  is  the-  time  to  lift  the  cloud  of  doubt, 
to  make  room  for  the  bright  sunshine  of  faith,  hope,  and  confidence. 

A  few  words  of  encourage- 
ment are  well  calculated  to 
inspire  confidence,  which  will 
do  so  much  to  lighten  the 
labor  of  the  anesthetizer  and 
to  shorten  the  stage  of  ex- 
citement. 

The  mental  condition  of 
the  patient  has  an  immense 
influence  in  hastening  or  re- 
tarding complete  anesthesia. 
The  patient  who  is  fearful 
and  lacks  faith  and  confi- 
dence will  require  a  much 
larger  quantity  of  the  anes- 
thetic than  if  the  opposite 
mental  conditions  prevail. 
With  the  exception  of  a  few 
words  of  assurance,  no  conversation  should  be  carried  on  between 
the  patient  and  the  anesthetizer  after  the  narcosis  has  commenced. 
Silence  must  be  strictly  enforced.  Anxious  relatives  and  useless 
bystanders  should  be  excluded.  Tying  of  hands  or  feet  or  strap- 
ping the  body  on  the  table  must  be  avoided,  as  such  brutal  pro- 
cedures savor  of  the  time  of  the  Inquisition  and  institutions  for 
punishment,  and  have  a  depressing,  if  not  a  revolting,  influence 
on  the  patient.  One  or  two  persons  can  always  control  the 
patient  should  he  become  violent.  The  masks  of  von  Esmarch 
and  Schimmelbusch  are  excellent  media  for  the  administration  of 
chloroform.  They  are  cheap  and,  what-  is  still  more  important, 
clean,  as  the  gauze  can  be  changed  every  time  they  are  used. 
The  wire  frame  also  can  be  sterilized  by  boiling.  I  have  devised 
an  inhaler  that  can  be  used  for  the  administration  of  both  chloro- 
form and  ether  (Fig.  3).     It  consists  of  an  open  cone  made  of  nickel- 


-Von  Esmarch' s  chloroform  inhaler  and 
chloroform  bottle. 


INHALERS. 


47 


plated  copper  wire,  which  can  be  molded  into  any  shape,  with  a 
ring  over  it  that  holds  the  towel  or  napkin  in  place.  If  chloroform 
is  used,  the  cone  is  covered  with  gauze,  held  in  place  b\-  the  ring  ; 
if  ether  is  administered,  the  towel  or  napkin  is  made  to  cover  only 
the  side  of  the  cone,  a  gauze  or 
sea-sponge  being  placed  in  the 
opening,  and  upon  this  the  ether 
is  dropped  continuously  until  tlie 
anesthesia  is  complete. 

Ah  ideal aiiiStJiiti::atio}i  is  char- 
acterized by  a  good  begiiu/ing  and 
a  happy  terjinnatioii.  T/ie  secret  of 
sitccess  ties  i/i  the  iiiaiuicr  in  zchich 

it  is  cojinne/iced  and  the  degree  of  care  exercised  during  its  continu- 
ance.  The  most  common  blunder  made  by  tlie  incompetent  anestJietizer 
is  to  place  the  mask  on  the  face  and  then  po7ir  on  the  chloroform  in  a 
stream,  strangling,  almost  suffocating,  tJie  patient  from  the  beginning. 
The  ajiesthesia  must  be  commenced  slozvly,  almost  insidiotisly,  zvithont 
any  strangling  or  great  discomfort 'to  tJie  patient.  A  few  drops  of 
chloroform  are  poured  on  the  mask  or,  in  the  absence  of  such,  on 
a  handkerchief  folded  once  or  twice  and  held,  for  a  few  minutes  at 
least,  four  inches  from  the  face,  when  it  is  brought  gradually  nearer. 


Fig.    2.- 


Schinimelbusch-von    Esmarch 
inhaler. 


\w^C=;:^i-^    VJICI3: 


Fig.  3. — Senn's  ether  and  cliloroform  inhaler;  mask  ojien  to  exhibit  wire  framework 
A,  Prepared  for  ether;   15,  prepared  for  chloroform. 


but  not  in  contact  with  the  face,  until  the  patient  has  become  accus- 
tomed to  the  irritating  effects  of  the  vapor.  Chloroform  should 
never  be  poured  on  the  mask  :  the  supply  must  be  exxlusively  by 
the  drop  method.  Ksmarch's  bottle  or  an  ordinary  bottle  loosely 
corked  with  a  strip  of  gauze  between  the  cork  and  the  neck  of  the 
bottle  answers  the  purpose  excellently  for  this  ideal  method  of 
administering  chIf>roform. 

As  soon  as  the  mask  has  been  brought  in  contact  with  the  face, 


48 


GENERAL    ANESTHESIA. 


the  chloroform  is  dropped  upon  it  continuously,  as  an  abundance 
of  air  passes  through  the  loose  meshes  of  the  gauze  or  handkerchief, 
thus  diluting  the  vapor  of  the  anesthetic  and  furnishing  the  neces- 
sary amount  of  oxygen.  It  is  during  the  beginning  of  the  narcosis 
that  the  patient's  mind  should  be  occupied  and  concentrated  upon 
something  foreign  to  the  procedure  he  is  undergoing.  This  can  be 
accomplished  in  one  of  two  ways  :  he  is  asked  to  count  slowly  until 
consciousness  is  lost,  or  is  requested  to  hold  one  of  the  upper 
extremities  in  a  vertical  position.  The  loss  of  consciousness  in  the 
latter  instance  is  announced  by  dropping  of  the  helpless  limb.  This 
stage  of  anesthesia  will  suffice  for  short  operations  and  when  it  is 
intended  to  operate  under  partial  anesthesia.  If  the  administration 
of  the  anesthetic  is  not  forced,  but  conducted  by  the  gradual,  insidi- 


Fig.  4. — Proper  position  of  patient  and  anesthetizer,  and  stand  for  the  anesthetics  and 

accessories. 

ous  drop  method,  adding  a  drop  every  five  to  ten  seconds,  patients 
are  usually  rendered  unconscious  in  from  eight  to  twelve  minutes 
without  much  struggling  or  resistance. 

All  complicated  inhalers  are  useless  and  more  dangerous  than 
the  simple  mask  or  plain  handkerchief.  Patients  who  are  very 
apprehensive,  fearful,  excited,  and  whose  confidence  can  not  be 
secured,  are  greatly  benefited  by  an  injection  of  i  of  a  grain  of  mor- 
phin  ten  to  fifteen  minutes  before  the  anesthesia  is  commenced, 
combined,  in  the  case  of  potators  or  persons  greatly  debilitated  by 
disease  or  the  effects  of  hemorrhage,  with  a  rectal  enema  of  two 
ounces  of  spirits,  diluted  with  warm  saline  solution.  In  such  per- 
sons  preliminary   treatment  of  this    kind   diminishes   or   modifies 


SIGNS.  49 

favorably  the  stage  of  excitement,  the  terror  of  the  anesthetizer, 
and  of  the  bystanders.  After  a  few  inhalations  the  patient  usually 
experiences  sensations  of  a  pleasant  nature,  breathing  is  accelerated, 
the  pulse  becoming  fuller  and  more  rapid.  Temporary  suspension 
of  respiration  at  this  stage  is  not  uncommon,  but  breathing  is 
resumed  on  making  the  request.  Crile  has  shown  by  his  experi- 
ments that  disturbances  of  respiration  during  the  early  stage  of 
anesthesia  are  remedied  very  promptly  by  elevating  the  head  and 
chest  of  the  patient,  while  during  the  later  staged  the  reverse  posi- 
tion is  more  useful.  Women,  children,  persons  greatly  debilitated, 
and  adults  of  exemplary  habits  often  pass  insensibly  into  complete 
anesthesia. 

Usually,  however,  complete  anesthesia  is  preceded  by  a  stage 
of  excitement  of  variable  duration.  It  is  during  this  stage  that  the 
anesthetizer  feels  keenly  the  weight  of  his  responsibility.  The 
patient  shouts,  prays,  swears,  sings,  cries,  laughs,  or  fights,  ac- 
cording to  his  temperament,  habits,  religious  belief,  occupation,  or 
social  position  in  life.  Tonic  and  clonic  spasms,  irregular  respira- 
tion, and  cyanosis  are  some  of  the  alarming  S3'mptoms  of  this  stage. 
A  turbulent  stage  of  excitement  may  be  confidently  expected  in 
persons  of  plethoric  disposition  and  intemperate  habits.  This  stage 
may  subside  in  a  few  moments  or  may  continue  for  ten  or  fifteen 
minutes,  even  for  a  longer  time.  Under  the  continued  administra- 
tion of  chloroform  by  the  drop  method  the  excitement  and  convul- 
sive movements  gradually  subside,  and  the  narcosis  passes  into  the 
stage  of  tolerance,  or  full  anesthesia.  This  is  announced  by  mus- 
cular relaxation,  snoring,  puffing  of  the  cheeks,  and  complete  loss 
of  consciousness  and  sensibility.  The  last  reflexes  disappear  upon 
the  surface  of  the  cornea,  mucous  membrane  of  the  nose,  and  in 
the  rectum.  The  pupil  is  contracted,  the  eyeballs  make  asymmetric 
movements,  the  pulse  becomes  smaller,  softer,  and  more  rapid. 
The  body-temperature  and  blood  pressure  are  diminished,  the 
re.spirations  become  more  rapid  and  shallow,  and  all  tissue  changes 
are  diminished.  This  is  as  fiir  as  it  is  advisable  and  safe  to  carry 
the  effect  of  the  anesthetic.  It  is  when  this  stage  has  been  reached 
that  the  assistant  who  takes  more  interest  in  the  operation  than  in 
the  welfare  and  safety  of  the  patient  commits  the  grossest  blunders 
and  places  the  life  of  the  patient  in  jeopardy  by  continuing  to  pour 
chloroform  on  the  mask.  If  the  anesthetic  is  continued  without 
interruption,  the  paralyzing  effect  reaches  the  medulla  oblongata, 
respiration  is  arrested,  the  heart  ceases  to  beat — occurrences  an- 
nounced without  any  other  premonitory  s)'mptonis  than  sudden 
dilatation  of  the  pupils. 

The  disappearance  of  the  corneal  reflex  is  an  indication  that 
the  anesthesia  has  reached  the  limits  of  safety,  and  the  further  use 
of  the  anesthetic  must  be  suspended  until  there  are  indications  of 
its  return.  Dilatation  of  tJic  pupils  is  always  a  signal  of  great  dan- 
ger and  a  strong  and  unmistakable  reminder  that  the  effects  of  the 
4 


50  GENERAL    ANESTHESIA. 

anesthetic  have  been  carried  beyond  the  liijiits  of  safety.  The  admin- 
istration of  the  anesthetic  must  be  immediately  suspended  until  the  pupils 
contract  and  the  corneal  reflex  returns. 

Grave  symptoms  and  accidents  are  most  likely  to  happen  in 
the  hands  of  inexperienced  anesthetizers,  in  nervous,  excitable  per- 
sons, the  weak  and  anemic,  obese  persons,  and  subjects  suffering 
from  organic  disease  of  the  heart,  lungs,  or  kidneys,  potators, 
and  the  habitual  users  of  opium,  chloral,  and  cocain. 

Accidents  during  Narcosis. — One  of  the  common  first  ill 
effects  of  the  anesthetic  is  a  disturbance  of  the  function  of  respira- 
tion. During  the  first  few  inhalations  the  patient  often  holds  his 
breath,  and  respiration  is  renewed  by  asking  the  patient  to  breathe. 
In  other  cases  the  vapor  of  chloroform  provokes  a  distressing 
cough,  but  the  cough  usually  subsides  as  the  anesthesia  proceeds. 
The  subjects  of  bronchitis,  pulm.onary  tuberculosis,  and  pleuritis 
are  most  likely  to  suffer  from  this  ill  effect  of  the  anesthetic.  The 
best  way  to  avoid  this  untoward  effect  is  to  administer  the  anes- 
thetic from  quite  a  distance  and  very  slowly  in  the  beginning. 

Prolonged  expiration,  interrupted  by  short  inspirations,  is  ob- 
jectionable because  it  interferes  with  a  free  entrance  of  the  vapor 
into  the  bronchial  tubes  and  consequently  retards  the  complete 
anesthesia.      The  regularity  of  respiration  in  such  cases  is  usually 


Fig.  5- — Musson's  sponge  holder. 


restored  by  talking  to  the  patient  or  by  a  light  blow  on  the  chest. 
Should  these  fail,  raise  the  body. 

Vomiting  may  occur  during  any  of  the  stages  of  narcosis, 
especially  when  the  stomach  of  the  patient  is  not  empty.  A  rapid 
narcosis,  by  causing  salivation,  hawking,  and  coughing,  is  most 
likely  to  produce  vomiting  during  the  early  stage  of  the  anesthesia. 
Vomiting  may  again  be  produced  by  the  swallowing  of  the  profuse 
saliva  mixed  with  chloroform  or  ether.  If  vomiting  is  provoked, 
the  head  must  be  turned  to  one  side  and  on  a  level  below  that  of 
the  body,  to  prevent  entrance  of  foreign  substances  into  the  air- 
passages.  An  abundance  of  mucus  and  saliva  in  the  pharynx  often 
provokes  vomiting,  in  which  case  the  removal  of  the  irritating 
material  with  the  sponge  holder  is  the  best  and  most  successful 
method  of  preventing  or  arresting  it.  Vomiting  from  a  neurotic 
source  can  be  arrested,  according  to  Joes,  by  making  digital  com- 
pression of  the  pneumogastric  and  phrenic  nerves  immediately  over 
the  sternal  articular  end  of  the  clavicle.  After  each  attack  of 
vomiting  the  cavity  of  the  mouth  should  be  cleared  of  food,  mucus, 
and  saliva  by  wiping  with  the  sponge,  towel,  or  handkerchief  before 
resuming  the  inhalation  of  the  anesthetic. 


ACCIDENTS    DURING    NARCOSIS. 


51 


If,  in  spite  of  all  precautions,  food  should  find  its  way  into  the 
air-passages,  an  immediate  tracheotomy  may  become  a  necessity. 
In  such  an  event  the  trachea  above  the  isthmus  of  the  thyroid 
gland  should  be  opened 
by  one  incision,  the 
trachea  being  held  im- 
movabh'  between  the 
thumb  and  index-finger 
of  the  left  hand.  A 
sudden  arrest  of  respir- 
ation, which  during  the 
beginning  of  the  narcosis  Fig.  6.— Ileistei's  gag. 

is   usually  overcome  by 

attracting  the  attention  of  the  patient  by  talking  to  him,  may  be- 
come of  the  most  serious  import  during  the  subsequent  stages  of 
the  narcosis.  After  a  iew  stertorous  respirations  and  stormy,  con- 
vulsive muscular  movements,  the  rima  glottidis  is  closed  by  muscu- 
lar spasm,  the  abdominal  wall  makes  a  few  inspiratoiy  contractions, 
sinks  in,  and  remains  board-like.  The  maxillary  bones  remain  in 
close  contact,  and  the  tongue  is  displaced  upward  and  backward 
in  such  a  way  that  the  passage  to  the  larynx  is  narrowed  to  an 
extent  incompatible  with  a  normal  supply  of  air  to  the  respiratory 
passages.  The  superficial  veins  of  the  forehead,  temples,  and  face 
become  turgid,  the  face  purple,  and  the  lips  cyanosed.  The  pulse, 
at  first  slow,  becomes  rapid,  and  lastly  almost  imperceptible. 

The  cause  of  approaching  asphyxia  in  such  cases  is  spasmodic 
contraction  of  the  muscles  and  larynx.     Prompt  action  is  necessary 

to  restore  the  embarrassed  cir- 
culation. The  mouth  must  be 
opened,  and  this  can  be  done 
most  exj)editiously  with  Heis- 
ter's  or  Henrotin's  gag ;  the 
tongue  is  grasped  and  drawn 
forward  with  forceps  of  special 
construction,  or  if  such  are  not 
on  hand,  with  a  pair  of  mouse- 
toothed  hemostatic  forceps.  My 
tongue  forceps  (Fig.  10)  com- 
bine an  infrapressure  with  a 
su{)ratenaculum  blade,  the  com- 
bination serving  to  hold  a  tongue 
with  the  least  possible  injury 
to  the  mucous  surfaces.  The 
under  blade  is  oval  in  form,  and  contains  an  ovoid  fenestra  with 
its  sharp  angle  at  its  distal  end  ;  the  faces  of  the  blade  margins 
slant  toward  tlie  center,  giving  to  the  whole  blade  a  sh'ghtly  con- 
cave form.  The  hooked  portion  of  the  blade  is  about  six  milli- 
meters in   length,  and   is  Ijent  at  a  right  angle  to  the  long  a.xis  of 


Fig.  7.  —  Henrotin's  gag. 


52 


GENERAL    ANESTHESIA. 


Fig.  8. — Von  Esmarch's  tongue-holding  forceps. 


the  instrument.  The  width  of  the  lower  blade  is  seventeen  miUi- 
meters,  and  of  the  fenestra  ten  millimeters.  The  instrument  is  of 
Hght  construction  and  is   5  ^  inches  in  length.      On  drawing"  the 

tongue  forward  the  air- 
passage  is  cleared  and 
the  anesthesia  continued 
with  additional  care.  In 
cases  in  which  the 
methods  just  advised  can 
not  be  employed,  and 
other  and  more  prompt 
measures  must  be  re- 
sorted to,  Kappeler  has 
suggested  two  valuable  procedures  intended  to  restore  respiration, 
both  of  which  have  been  extensively  adopted  and  have  been  proved 
to  be  most  satisfactory.  The  first  procedure  consists  in  elevating 
the  lower  maxilla,  and  with  it  the  base  of  the  tongue,  epiglottis, 
and  hyoid  bone.  The  method  of  accomplishing  this  is  well  shown 
in  figure  ii.  The  same  object  is  secured  by  standing  in  front  of 
the  patient  and  using  the  four  fingers  of  both  hands  in  the  form 
of  a  hook,  and  applying  them  above  the  angle  of  the  jaw,  making 
traction  in  a  forward  direction. 

In  practising  this  procedure  the  mouth  should  not  be  opened  to 
any  extent,  for  if  this  is  done,  the  base  of  the  tongue  is  not  lifted 
forward,  but  upward,  which  would  interfere  with  the  free  ingress  of 
air  into  the  air-passages.      Some  care  is  necessary  in  making  the 


Fig-  9.— Houze's  tongue-holding  forceps. 


manipulations,  as  otherwise  some  swelling  of  the  temporomaxillary 
joints  and  parotid  glands  is  liable  to  follow  as  an  unpleasant  remote 
complication.  The  second  suggestion  of  Kappeler,  in  such  cases 
where  the  tongue  is  difficult  of  access,  consists  in  the  use  of  a 
sharp  tenaculum,  with  which  the  hyoid  bone  is  transfixed  through 
the  intact  skin,  which  is  then  drawn  forward,  and  with  it  the  base 
of  the  tongue  and  epiglottis,  thus  affording  free  entrance  of  air  into 
the  lower  tract  of  the  respiratory  passage  with  the  jaws  set. 

Fenger  has  recently  elaborated  this  method  of  relieving  the 
embarrassed  respiration,  due  to  the  same  cause.  If,  in  relieving 
the  mechanical  difficulties  interfering  with  the  free  entrance  of  air 
by  the  means  described,  respiration  is  not  promptly  restored,  the 
wiper  must  be  used  to  free  the  supralaryngeal  space  of  mucus  or 


ACCIDENTS    DURING    NARCOSIS. 


53 


Fig.  lO. — Senn's  tongue-holding  forceps. 


blood,  which,  in  such  an  event,  directly  causes  the  mechanical 
obstruction  to  the  entrance  of  air.  Should  this  fail  to  afford  the 
expected  relief,  a  rapid  tracheotomy  and  direct  artificial  respira- 
tion through  it  ac- 
cording to  Fell's 
method  constitute  the 
dernier  ressort  to  re- 
establish the  sus- 
pended respiration. 
If  respiration  is  not 
restored  upon  the  re- 
moval of  mechanical 
impediments,  as  is  so 
often  the  case  when 
the  narcosis  is  carried  beyond  safe  limits,  artificial  respiration 
must  be  resorted  to  promptly  and  continued  until  respiration  is 
reestablished  or  all  hope  of  restoring  life  has  vanished.  While 
this  is  being  done,  an  assistant  maintains  the  patency  of  the  respira- 
tory tract  by  employing  a  mouth  gag  or  hemostatic  forceps  to  sep- 
arate the  jaws,  and  by  holding  the  tongue  well  forward  by  for- 
ceps or  by  a  ligature  passed  through  the  median  line  near  the  tip 
of  the  organ.  While  artificial  respiration  is  being  made,  the  foot 
of  the  table  is  elevated  so  as  to  incline  the  body,  with  the  head 
downward,  at  an  angle  of  45  degrees. 

The  one  who  makes  artificial  respiration  stands  behind  the  head 
of  the  patient,  grasps  both  elbows,  with  the  arms  extended,  and  by 
traction  brings  the  arms  to  the  side  of  the  head  so  as  to  expand 
the  chest-wall  to  its  utmost.  Then  the  movement  is  reversed  by 
brinsfine  the  arms,  with  forearms  flexed,  to  the  sides  of  the  chest, 

which  is  then  forcibly  compressed 
for  the  purpose  of  forcing  out 
from  the  air-passages  as  much 
as  possible  of  the  contained  air. 
These  movements  must  be  made 
deliberately  and  not  spasmodically. 
This  is  Sylvester's  method,  the  only 
one  of  the  many  methods  of  artifi- 
cial respiration  that  have  been  sug- 
gested which  is  entitled  to  confi- 
dence in  such  cases.  The  res- 
piratory movements  are  repeated 
eighteen  to  twenty  times  a  minute, 
resembling  in  this  respect  normal  respiration.  Nothing  is  gained 
by  increasing  the  frequency. 

The  success  of  artificial  respiration  depends  on  the  thorough- 
ness with  which  every  movement  is  made.  If  respiration  is  not 
restored  jiromptly,  there  is  no  reason  for  despair,  as  success  has 
followed  efforts  continued  fijr  half  an   hour  or  more.      The  efforts 


Fig.  II. — Metluxl  of  pushing  the 
lower  jaw  forward  to  prevent  obstruc- 
tion to  breathing. 


54 


GENERAL   ANESTHESIA. 


Sylvester's  method  of  performing  artificial  respiration. 


should  be  continued  for  at  least  half  an  hour  unless  unmistakable 
evidences  of  death  make  their  appearance  and  warrant  suspension 

of  further  efforts 
at  resuscitation. 
During  the 
time  attempts 
are  being  made 
to  restore  res- 
piration, other 
means  of  coun- 
teracting the 
toxic  effect  of 
chloroform  are 
employed.  The 
most  potent 
physiologic  an- 
tidote of  chloro- 
form is  strych- 
nin. Horatio 
C.  Wood  ad- 
vises heroic  doses.  In  adults  the  first  dose  should  not  be  less  than 
one-sixth  of  a  grain  by  subcutaneous  injection.  This  may  be  safely 
repeated  in  ten  or  fifteen  minutes  if  the  nervous  centers  do  not 
respond  to  the  first  dose.  Inhalations  of  nitrite  of  amyl  stimulate 
the  heart's  action  and  are  well  calculated  to  relieve  the  stagnant 
capillary  circulation.  Slapping  the  chest  with  a  towel  wrung  out 
of  cold  or  hot  water 
and  rubbing  of  the 
extremities  are  valu- 
able agents  in  ac- 
complishing the  same 
object.  Faradization 
of  the  phrenic  nerve 
(Duchenne,  von 
Ziemssen)  is  another 
valuable  resource  in 
restoring  respiration 
temporarily  sus- 
pended by  the  toxic 
action  of  chloroform 
on  the  respiratory 
center.  The  two  elec- 
trodes are  applied, 
one  on  each  side  of 
the  neck  over  the 
clavicle,  at  the  outer 
Althoug-h 


Fig-  13- 


-Sylvester's  method  of  performing  artificial 
respiration. 


border    of  the  sternocleidomastoid  muscle, 
the   immediate   cause  of  death  from   chloroform   is 
generally  its  toxic  action  on  the  center  of  respiration,  alarming  and 


ACCIDENTS    DURING    NARCOSIS.  55 

fatal  complications  may  set  in  which  are  directly  referable  to  its 
depressing  effect  on  the  heart  muscle.  Such  accidents  occur 
usually  when  least  expected,  and  with  a  suddenness  that  is  appall- 
ing. In  a  moment  the  color  of  the  face  is  changed  to  a  deadly 
pallor  ;  the  pupils  dilate  and  do  not  respond  to  light ;  the  corneal 
reflex  disappears  ;  the  lower  jaw  drops,  cadaver-like  ;  the  pulse  is 
either  very  small,  rapid,  and  flickering,  or  imperceptible  ;  the  heart- 
sounds  are  inaudible  ;  bleeding  in  the  wound  ceases  ;  respiration, 
although  shallow  and  irregular,  may  continue  for  a  short  time  until 
it  ceases  after  a  few  spasmodic  efforts,  similar  to  those  observed  in 
a  dying  person.  Such  a  terrible  scene  is  fortunately  very  rare,  and 
when  it  does  occur,  it  is  most  frequently  met  in  anemic  patients 
and  in  those  the  subjects  of  organic  disease  of  the  heart.  Never- 
theless, it  may  occur  in  persons  in  perfect  health,  more  especially 
if  they  are  apprehensive,  nervous,  and  excited  before  the  operation. 

Prompt  action  is  urgently  indicated  in  all  cases  of  anesthesia  in 
which  heart  depression  follows  as  one  of  the  toxic  effects  of  the 
anesthetic.  Inversion  of  the  body,  suggested  first  by  Nelaton  in 
1 86 1,  is  the  first  measure  to  be  performed  in  such  cases.  To 
accomplish  this  in  the  shortest  possible  space  of  time  the  foot-end 
of  the  operating  table  is  elevated  to  an  angle  of  at  least  45  degrees. 
This  position  relieves  the  existing  cerebral  anemia,  and  by  doing 
so  the  heart  center,  and  the  heart  likewise,  is  stimulated  by  the 
increased  supply  of  blood.  The  patient  is,  at  the  same  time,  placed 
most  favorably  for  artificial  respiration,  which  becomes  necessary 
if  there  is,  as  is  so  often  the  case,  an  inhibition  of  the  respiratory 
function.  Heart  stimulants  by  hypodermic  injection  are  always 
indicated.  Of  these  digitalis,  strychnin,  alcohol,  camphor,  and  coffee 
will  prove  most  effectual.  Tincture  of  digitalis  or  digitalin,  the 
former  in  half-dram  doses,  the  latter  in  doses  of  from  yi^^  to  -^-^  of 
a  grain  every  ten  or  fifteen  minutes  until  reaction  takes  place,  will 
prove  most  successful.  In  very  grave  cases  it  should  be  combined 
with  strychnin  in  decided  doses.  Camphorated  oil,  administered 
in  the  same  way,  in  doses  of  two  or  three  syringefuls,  is  a  very 
powerful  cardiac  stimulant  and  entitled  to  confidence  in  such  cases. 
Alcohol  in  the  form  of  whisky,  brand}',  cognac,  or  rum,  can  be 
given  at  short  intervals  by  subcutaneous  injections  or  by  the  rec- 
tum. The  application  of  dry  heat  to  the  extremities  and  trunk 
should  never  be  neglected.  Friction  with  hot  cloths  is  a  potent 
vascular  stimulant  and  will  be  useful  in  aiding  the  other  remedies 
in  restoring  the  general  circulation. 

Heart  massage,  as  advised  by  Konig,  will  accomplish  much  in 
stimulating  the  organ  to  renewed  action.  The  one  who  attends  to 
this  jxirt  of  the  resuscitation  of  the  patient  stands  on  the  left  of  the 
patient  anri  makes  compression  with  the  ball  of  the  right  thumb 
between  the  apex-beat  and  the  left  margin  of  the  sternum.  The 
compressions  should  be  firm  and  rhythmic,  at  the  rate  of  120  a 
minute,  and  should   be  continued  until  return  of  the  pulsations  in 


56  GENERAL    ANESTHESIA. 

the  carotid  artery  is  noticeable  and  the  pupils  contract.  Intra- 
venous infusion  of  normal  salt  solution  will  undoubtedly  yield 
encouraging  results  in  desperate  cases. 

The  treatment  outlined  must  be  continued  until  the  pulse  at  the 
wrist  returns  in  fair  volume  and  the  pupils  contract.  In  fatal  cases 
the  treatment  should  be  continued  for  a  sufficient  length  of  time  to 
satisfy  the  operator  and  those  who  are  later  called  upon  to  investi- 
gate the  cause  of  death,  that  everything  known  to  science  was  done 
to  restore  the  patient  to  life. 

Ether  Anesthesia. — Sulphuric  ether,  C^Hj,p,  was  introduced 
as  a  general  anesthetic  by  Jackson  and  Morton  in  1846.  The  first 
operation  under  ether  anesthesia  was  performed  in  the  Massachu- 
setts General  Hospital,  and  the  sponge  used  is  one  of  the  many 
precious  relics  in  medicine  and  surgery  carefully  preserved  in  that 
institution. 

Ether  for  anesthetic  use  should  contain  no  alcohol,  water,  acetic 
acid,  sulphuric  acid,  or  fusel  oil.  If  the  purity  of  the  ether  is  ques- 
tionable, tests  for  these  substances  should  be  made.  Ether  is  one 
of  the  most  volatile  of  all  liquid  substances,  and  the  vapor  is  quickly 
absorbed  by  the  mucous  membrane  of  the  air-passages.  The  odor 
of  the  strong  vapor  is  pungent,  and  when  the  vapor  is  brought  in 
contact  with  mucous  surfaces,  it  produces  a  marked  irritation  and 
hypersecretion. 

The  physiologic  effect  of  ether  is  closely  allied  to  that  of  chloro- 
form, differing,  however,  from  the  latter  in  that  the  intracranial 
blood  supply  is  rather  increased  than  diminished  under  full  anes- 
thesia and  it  is  less  likely  to  cause  depression  of  the  heart's  action. 
The  ultimate  toxic  effects  on  the  brain  and  spinal  cord  are  almost 
identical  with  those  of  chloroform,  and  hence  its  use  demands  the 
same  preliminary  preparations  and  precautions  during  its  adminis- 
tration. 

The  disadvantages  of  ether  as  compared  with  those  attending 
and  following  the  administration  of  chloroform  consist  in  the  well- 
known  profuse  salivation,  coughing,  vomiting,  and  greater  hyper- 
emia of  important  internal  organs.  While  the  immediate  mortality 
of.  ether  anesthesia  is  less  than  that  of  chloroform,  there  is  but 
little  doubt  that  the  difference  would  be  more  than  balanced  by  the 
greater  number  of  deaths  from  complications  following  its  use,  such 
as  ether  bronchitis  and  pneumonia  and  ether  nephritis.  I  have 
seen  a  number  of  such  cases  in  my  own  practice,  and  have  knowl- 
edge of  others  that  occurred  in  the  practice  of  my  colleagues,  cases 
in  which  there  could  be  no  doubt  that  the  deaths  were  caused  by 
complications  resulting  from  the  remote  irritating  or  toxic  effects 
of  ether.  Such  remote  causes  of  death  attributable  to  the  anes- 
thetic must  necessarily  occur  most  frequently  in  the  practice  of  sur- 
geons who  use  ether  exclusively,  and  who  do  not  look  for  or 
ignore  the  contraindications  for  its  employment.  It  is  equally  cer- 
tain that  deaths,  immediate  and  remote,  from  ether  anesthesia  occur 


ETHER    ANESTHESIA.  57 

with  greater  frequency  when  the  anesthetic  is  given  quickly  and  care- 
lessly than  when  administered  slowly  and  carefully  by  an  expert. 
It  is  a  very  serious  mistake  to  administer  pure  ether  vapor  from  the 
very  beginning,  as  is  done  by  many,  with  the  expectation  of  hasten- 
ing the  narcosis.  All  such  attempts  are  productive  of  intense  irri- 
tation of  the  upper  air-passages,  profuse  salivation,  coughing,  and 
very  often  \'omiting  and  violent  attempts  to  secure  relief  by  remov- 
ing the  cone. 

It  has  been  claimed  that  a  certain  amount  of  ether  is  necessary 
to  produce  anesthesia,  and  that  the  sooner  it  reaches  the  circula- 
tion, the  prompter  the  narcosis.  Those  who  support  this  view  are 
of  the  opinion  that  in  ether  anesthesia  the  admixture  of  air  is  not 
only  unnecessary,  but  that  it  retards  the  narcosis  without  increas- 
ing its  safety.  Such  arguments  are  no  longer  tenable.  The  safest 
way  to  administer  ether  is  to  proceed  slowly  and  dilute  the  vapor 
with  a  liberal  admixture  of  air.  All  cones  made  of  impermeable 
material  should  be  avoided.  The  mask  devised  by  me  is  constructed 
on  the  principle  of  administering  ether  well  diluted  with  atmos- 
pheric air  continuously.  All  complicated  devices  for  ether  inhala- 
tion should  be  avoided,  as  enough  air  should  be  admitted  to  dilute 
the  vapor  sufficiently  to  diminish  its  irritating  qualities  and  to  sup- 
ply the  blood  with  a  sufficient  quantity  of  oxygen  so  long  as  the 
patient  remains  under  the  influence  of  the  anesthetic. 

The  best  ether  inhaler  is  an  open  cone  made  of  a  starched  towel 
or  stiff  paper  placed  over  a  wire  framework.  The  opening  in  the 
apex  of  the  cone  should  be  at  least  three  inches  in  diameter  and 
loosely  packed  with  a  sponge,  loose  gauze,  or  a  small  handker- 
chief The  absorbent  material  is  saturated  with  ether  from  the  in- 
side of  the  cone.  The  cone  must  be  held  at  least  six  inches  from 
the  face,  and  as  the  patient  becomes  accustomed  to  the  odor  of  the 
ether  it  is  brought  slowly  nearer,  until  it  rests  evenly  on  the  sur- 
face and  close  enough  to  prevent  the  entrance  of  air  underneath  it. 
This  part  of  the  anesthetization  should  be  done  without  causing  any 
great  struggling  on  the  part  of  the  patient,  after  which  the  cone 
remains  in  place  until  the  anesthesia  is  complete.  The  ether  is 
poured  on  the  absorbent  material  in  small  quantities,  through  the 
perforation  in  the  cone,  at  intervals  of  ten  seconds,  thus  continuing 
the  inhalation  from  the  beginning  until  the  completion  of  the  anes- 
thesia without  interruption  unless  symptoms  arise  which  necessitate 
temporary  suspension. 

It  is  a  very  common  experience  when  anesthesia  is  progressing 
favorably  that  when  the  cone  is  removed  for  the  purpose  of  adding 
a  new  supply  of  ether,  a  .sen.se  of  suffocation,  as  soon  as  the  cone  is 
applied  to  the  face,  brings  with  it  a  renewal  of  the  disagreeable 
manifestations  aroused  during  the  beginning  of  the  etherization. 

It  mu.st  not  be  forgotten  tliat  ether  is  a  highly  inflammable  sub- 
stance, and  on  this  account  special  care  must  be  exercised  in  its 
use  in  operations  by  the  aid  of  lamplight  and  in   the   u.se   of  the 


58  GENERAL    ANESTHESIA. 

Paquelin  cautery  near  the  ether  cone.  Accidents  during  ether  nar- 
cosis are  met  by  the  same  treatment  as  has  been  described  under 
the  head  of  Chloroform  Anesthesia.  The  subject  of  general  anes- 
thesia may  be  summarized  briefly  as  follows  : 

Proper  preparation  of  patient ;  adequate  snpply  of  the  different 
antidotes  and  means  of  restoring  suspended  respiration  ;  pure  anes- 
thetics and  slow,  continiions  inhalation  ;  dilution  of  the  vapor  with  a 
liberal  snpply  of  air ;  iinrendtting  vigilance  and  prompt,  efficient,  and 
persistent  treatment  when  unfavorable  or  alarming  symptoms  make  it 
necessary  to  interrupt  the  anesthesia. 

Local  Anesthesia. — A  safe  local  anesthesia  is  the  ideal  condi- 
tion under  which  to  operate,  as  it  relieves  the  operator  from  all 
anxiety  regarding  the  dangers  incident  to  the  administration  of  a 
general  anesthetic.  Much  progress  has  been  made  during  the  last 
decade  in  enlarging  the  field  for  operations  and  in  intensifying  the 
degree  of  anesthesia,  but  most  of  the  major  operations  are  per- 
formed in  localities  not  adapted  for  local  anesthesia  and  require  too 
long  a  time  to  come  within  the  practical  range  of  local  anesthetics. 
For  these  reasons  it  is  more  than  doubtful  that  local  anesthesia  will 
ever  entirely  displace  general  anesthesia.  The  temporary  suspen- 
sion of  the  function  of  the  brain  during  most  of  the  capital  opera- 
tions is  a  benefit  to  the  patient  and  a  source  of  comfort  to  the 
surgeon. 

Local  anesthesia  is  a  desideratum  that  has  been  sought  for 
years.  The  first  efforts  in  this  direction  consisted  of  firm  pressure 
on  the  main  nerve -trunks  of  the  part  operated  upon,  which  was 
expected  to  interrupt,  at  least  to  a  certain  extent,  peripheral  im- 
pressions. This  was  aided  in  some  cases  by  circular  constriction, 
which  increased  the  anesthetic  effect  of  compression  by  retarding  or 
arresting  the  circulation  in  the  field  of  operation.  This  primitive 
method  of  procuring  local  anesthesia  did  something  in  the  way  of 
diminishing  pain.  The  next  step  in  the  same  connection  consisted 
in  making  use  of  cold  as  a  local  anesthetic.  This  agent  came  into 
use  from  the  well-known  fact  that  in  tissues  partly  or  completely 
frozen  sensation  is  suspended.  Ice  alone  applied  for  a  sufficient 
length  of  time  produces  a  decided  local  anesthetic  effect  which 
includes  the  whole  thickness  of  the  skin.  The  degree  of  cold  is 
increased,  and  its  anesthetic  properties  intensified,  by  mixing  com- 
mon salt  with  crushed  ice.  The  ice  and  salt  should  be  well  mixed 
and  applied  in  a  gauze  bag  or  in  a  towel.  As  soon  as  the  skin  is 
whitened  by  the  cold,  an  incision  can  be  made  through  it  with  little 
or  no  pain.  This  is  one  of  the  simplest  and  at  the  same  time  most 
efficient  procedures  for  preventing  pain  in  excising  small  tumors  of 
the  skin  and  in  incising  superficial  abscesses. 

The  next  advance  made  in  the  use  of  local  anesthetics  consisted 
in  the  substitution  of  highly  volatile  fluids  for  ice.  Richardson 
used  sulphuric  ether  in  the  form  of  a  spray.  An  ordinary  hand 
spray  answers  an  excellent  purpose.    Under  the  action  of  the  spray 


LOCAL    ANESTHESIA. 


59 


the  skin  is  partly  frozen  in  a  very  few  seconds,  and  a  small  incision 
can  be  made  without  causing  any  pain.  The  anesthetic  area  in  this 
method  of  local  anesthesia  is  small,  as  the  spray  must  be  concen- 
trated for  the  purpose  of  producing  the  anesthetic  degree  of  cold. 
During  the  local  reaction  from 
the  freezing  process  the  patient 
experiences  a  prickling  pain  in 
the  part,  which  can  be  relieved 
to  some  degree  by  immersion 
in  warm  water.  More  effective 
than   ether  are   the  chlorids   of 

methyl  and  ethyl.  The  first  is  applied  to  the  skin  in  a  compress 
saturated  with  it  and  held  against  the  part  to  be  frozen.  The 
area  of  anesthetization  is  regulated  in  this  instance  by  the  size 
of  the  compress,  possessing  in  this  respect  a  decided  advantage 
over  the  ether  and  chlorid  of  ethyl  spray.  This  local  anesthetic 
was  introduced  by  Bailly.  Chlorid  of  ethyl  is  so  volatile  that  it 
boils  at  the  temperature  of  the  body.      For  local  anesthesia  it  is 


Fig.  14. — Small  glass  tube  of  chlorid  of 

ethyl. 


Fig-  15- — Lewis'  needles  and  syringe  for  infiltration  anesthesia. 


^£^ 


Fig.  16. — Infiltration  anf-slhesia.      Tiie  syringe  point  stops  at  tlie  papillary  layer,  and  the 
fluid  lodges  in  the  skin  itself  (Van  Hook). 

put  u()  in  glass  tubes  (Bengue),  with  a  neck  supplied  with  a  metallic 
attachment  from  which  the  spray  escapes  under  bod}'-tcmi)eratin-e 
on  removing  the  metallic  cork  (I''ig.  14).  In  using  tlie  .spray  the 
tube  is  held  for  a  few  moments  in  the  hollow  of  the  liand,  when  the 
cork  is  removed  and  the  spray  begins.  The  indications  for  the  use 
of  the  chlorid  of  ethyl  spray  are  the  .same  as  for  the  ether  spray. 


6o 


GENERAL   ANESTHESIA. 


Cocain  (KoUer)  is  one  of  the  most  recent  and  useful  of  local 
anesthetics.  Applied  to  mucous  surfaces  in  solution  of  from  2  to  lo 
per  cent,  it  produces  a  complete  superficial  anesthesia  in  from  three 

to  five  minutes.  It  is  used  most  exten- 
sively in  ophthalmic  work  and  in  opera- 
tions upon  the  mucous  membrane  of  the 
nose,  pharynx,  larynx,  and  external  geni- 
tals. The  surface  must  be  carefully 
cleansed  before  the  solution  is  applied. 
It  has  no  effect  on  the  intact  skin.  To 
procure  anesthesia  of  the  skin  it  is  nec- 
essary to  inject  the  solution  into  it,  and 
not  under  it,  as  is  so  often  done.  If  a 
certain  area  of  skin  is  to  be  anesthetized, 
the  injections  are  to  be  made  with  a  hy- 
podermic syringe  with  a  fine  point,  under 
the  strictest  precautions,  using,  in  pref- 
erence, a  fresh  solution,  the  asepticity 
of  which  can  be  depended  upon.  The 
needle-point  is  entered  obliquely,  and 
enough  fluid  is  injected  to  raise  a  circu- 
lar portion  of  the  skin,  which  then  re- 
sembles a  blister. 

Tension  is  an  important  element  in 
the  anesthetization  of  the  skin,  as  well  as 
the  local  anemia  produced  by  it.  These 
punctures  are  made  in  a  straight  line 
if  the  incision  is  to  be  made  in  this 
direction  ;  circular  or  oval,  according  to  the  nature  of  the  operation, 
and  sufficiently  close  together  so  that  the  different  centers  of  local 
anesthesia  touch  each  other.  After  the  first  puncture  is  made,  the 
needle  is  always  inserted  through  the  skin  already  anesthetized. 

Cocain  is  no  indifferent  drug.  Many  cases  of  severe  intoxica- 
tion and  a  few  deaths  from  its  use  have  been  reported.  In  opera- 
tions requiring  ex- 
tensive cocainiza- 
tion  it  is  well  to 
constrict  the  blood- 
vessels, wherever 
this  can  be  done, 
by  elastic  constric- 
tion, so  as  to  guard 
against  its  early 
and  free  entrance  into  the  circulation.  The  toxic  effects  of  cocain 
are  manifested  by  pallor,  dizziness,  fainting,  headache,  and  delirium, 
symptoms  which  should  always  place  the  surgeon  on  guard  and 
which  demand  immediate  suspension  of  its  further  use.  To  relieve 
the  condition  nitrite  of  amyl  must  be  administered  by  inhalation, 


Fig.  17. — Showing  how 
the  successive  wheals  are  raised, 
the  point  of  the  syringe  being 
inserted  at  the  points  marked 
by  the  dots  (Schleich). 


18. — Showing  mode  of  injecting  the   fluid   under  an 
abscess  (Schleich). 


LOCAL    ANESTHETICS.  6 1 

to  be  followed,  if  the  patient  does  not  rally  promptly,  by  subcuta- 
neous injections  of  strychnin  and  alcohol  by  the  mouth  or  rectum. 

For  subcutaneous  use  the  cocain  solution  has  been  displaced 
almost  entirely  by  Schleich's  infiltration  method.  This  method 
consists  in  the  use  of  cocain  and  morphin  in  small  doses,  in  normal 
salt  solution  sufficient  in  amount  to  produce  the  necessary  degree 
of  tension  and  local  anemia.  Schleich  recommends  the  following 
solutions,  which  are  known  as  No.  i,  2,  and  3,  according  to  their 
strength. 

Schleich's  Solution. — 

A^o.    I,  Strotig. — Cocain  muriate, 0.2       gm.  (3  gr. ) 

Morpliin  muriate, 0.025  gm.  (|  gr.) 

Sodium  chlorid, 0.2       gm.  (3  gr. ) 

Sterilized  water, 100         c.c.  (3|  fl.oz.). 

No.  2,  Normal. — Cocain  muriate, O.I       gm.  (l^  gr.) 

Morphin  muriate, 0.025  g™-  (f  g''-) 

Sodium  chlorid, 0.2       gm.  (3  gr.) 

Sterilized  water,     . 100  c.c.  (3|  fl.oz.). 

No.  J,    IVeak. — Cocain  muriate, o.oi     gm.  (i  gr.) 

Morphin   muriate, 0.025  gm.  (|  gr. ) 

Sodium  chlorid, 0.2       gm.  (3  gr. ) 

Sterilized  water loo  c.c.  (3I  fl.oz.). 

To  each  of  the  solutions  two  drops  of  a  5  per  cent,  solution  of 
carbolic  acid  may  be  added  if  they  are  intended  for  stock  solutions, 
to  preserve  them  in  a  more  nearly  perfect  antiseptic  state. 

Of  the  No.  I  .solution  as  much  as  6^  fluidrams  may  be 
injected  during  one  operation  ;  of  the  No.  2  as  much  as  3|  fluid- 
ounces  ;  and  of  No.  3  even  a  pint  has  been  used  with  safety.  The 
normal  solution  is  the  one  generally  used,  the  strong  and  weak 
solutions  being  applicable  only  in  exceptional  cases. 

In  infants  and  children  a  general  anesthetic  is  preferable  to  local 
infiltration  by  Schleich's  method.  Injections  of  cocain  solution 
into  any  of  the  mucous  pa.ssagcs,  more  particularly  the  urethra, 
are  attended  by  great  danger  of  intoxication,  and,  on  the  whole,  are 
objectionable  on  this  account.  In  operations  extending  beyond  the 
skin  the  infiltration  is  repeated  as  often  as  required,  always  bearing 
in  mind  the  quantity  of  the  solution  used.  In  this  manner  many 
tedious  operations,  such  as  thyroidectoni}-  (Kocher),  can  be  per- 
formed almost  painlessly. 

Eucain. — Eucain  has  recently  come  largely  into  use  as  a  substi- 
tute for  cocain  as  a  local  anesthetic.  It  is  claimed,  and  apparently 
for  good  reasons,  that  it  produces  local  anesthesia  as  satisfactorily 
as  cocain,  without  depressing  the  action  of  the  heart,  one  of  the 
great  disadvantages  of  cocain.  F^ucain  A,  the  first  preparation 
u.sed,  was  found  unreliable,  and  has  given  place  to  eucain  B,  which 
in  a  2  per  cent,  solution  injected  along  the  line  of  the  cutaneous 
nerves  produces  complete  local  anesthesia.  A  syringeful  of  a  2 
per  cent,  .solution  (twenty  minims)  is  injected  into  the  subcutaneous 
tissues  in  three  or  four  places,  and  the  .syringe  is  again   filled   and 


62  PROPHYLACTIC    HEMOSTASIS. 

used  to  moisten  the  wound  or  inject  if  necessary — forty  minims  in 
all.  Anesthesia  is  produced  almost  instantly,  and  lasts  at  least 
half  an  hour — long  enough  to  perform  minor  operations. 


CHAPTER  IV. 

PROPHYLACTIC  HEMOSTASIS. 

The  intelligent  selection  and  employment  of  appropriate  and 
efficient  prophylactic  measures  are  as  important  and  of  as  far- 
reaching  value  in  surgery  as  in  medicine.  The  surgeon  who  is  in 
possession  of  the  necessary  degree  of  knowledge  to  anticipate  cer- 
tain unfavorable  results  in  the  case  of  accidental  injuries  and  of 
operations,  and  who  employs  timely  and  rational  treatment  calcu- 
lated to  prevent  them,  is  the  one  who  is  master  of  the  situation  and 
who  will  benefit  his  patients  to  the  greatest  extent ;  his  work  will 
be  a  credit  to  himself  and  to  the  profession  to  which  he  belongs. 

Hemostasis  and  the  prevention  of  wound  infection  are  the  two 
subjects  in  prophylaxis  in  which  the  modern  surgeon  is  most 
deeply  interested.  The  wounded  are  safe  in  the  hands  of  the  sur- 
geon who  knows  how  to  prevent  and  arrest  hemorrhage,  and  who 
is  familiar  with  the  technic  of  antiseptic  and  aseptic  precautions. 
Emergency  surgery  deals  necessarily  largely  with  hemostasis  and 
the  prevention  of  wound  infection.  Every  practitioner  of  medicine 
should  be  fully  conversant  with  these  subjects  if  he  expects  to 
merit  the  confidence  of  his  profession  and  of  his  clientele.  Pro- 
phylactic hemostasis  has  been  developed  to  a  wonderful  degree  of 
perfection  during  the  last  quarter  of  a  century.  The  numerous 
resources  for  the  prevention  of  hemorrhage  that  are  at  our  dis- 
posal at  the  present  time  have  contributed  much  toward  the  devel- 
opment of  modern  aggressive  surgery.  They  have  converted  the 
bloody  operating  theater  into  an  almost  bloodless  dissecting  room. 
They  have  enabled  surgeons  to  perform  operations  of  which  they 
never  dreamed  before  they  came  into  use.  For  the  time  being 
they  transform  the  part  to  be  operated  upon  into  a  bloodless 
cadaver.  Anesthesia  and  prophylactic  hemostasis  have  largely 
done  away  with  the  necessity  of  reckless,  rapid  operating.  With 
the  patient  anesthetized  and  the  part  to  be  operated  upon  rendered 
bloodless,  the  surgeon  can  now  proceed  slowly  and  carefully,  imi- 
tating the  anatomist  in  making  a  difficult  dissection  in  all  cases  in 
which  great  care  and  delicacy  are  required  in  the  performance  of 
the  operation.  The  surgeon  who  is  familiar  with  the  use  of  the 
various  prophylactic  hemostatic  resources  will  perform  operations 
from  which  others  not  in  possession  of  such  knowledge  would 
shrink.     The  best  surgical  work  is  done  by  men  who  can  perform 


ELEVATION. 


63 


the  most  difficult  operations  with  the  least  possible  sacrifice  of 
blood.  Bloodless  operating  not  only  saves  valuable  tissue  for  the 
patient,  but  it  places  the  operator  in  a  position  to  apply  with  advan- 
tage his  knowledge  of  anatomy  to  the  utmost  extent  in  the  treat- 
ment of  injuries  and  in  the  removal  of  diseased  tissue  the  presence 
of  which  furnishes  the  indication  for  the  operation. 

The  simplest  prophylactic  hemostatic  agent  is  elevation. 

Elevation. — The  influence  of  the  force  of  gravitation  on  the 
blood  supph'  of  a  limb  becomes  apparent  by  placing  the  arm  in  dif- 
ferent positions.  If  one  of  the  upper  extremities  is  allowed  to  hang 
by  the  side  of  the  body  and  the  muscles  are  fully  relaxed,  the  veins 


Fig.  19. — Eleva- 
tion of  the  upper  ex- 
tremity in  the  treat- 
ment of  hemorrhage. 


Fig.  20. — Gun-stack  for  elevation  of  the  lower  extremity. 


become  turgid,  the  capillaries  distended,  the  volume  and  force  of 
the  radial  pulse  arc  markedly  increased,  and  a  sense  of  fullness  and 
weight  is  experienced.  If  the  arm  is  now  elevated  and  held  in  the 
vertical  position  (Fig.  19),  within  a  few  minutes  the  cyanosed  appear- 
ance of  the  skin  vanishes  and  gives  way  to  pallor,  the  overdistended 
veins  collapse  and  are  no  longer  visible,  the  radial  pul.se  loses  much 
of  its  volume  and  force,  and  the  sen.se  of  weight  and  fullness  is 
promptly  relieved.  The  arterial  blood  supply  to  the  elevated  limb 
i.s  diminished  and  the  return  of  venous  blood  favored — vascular 
conditions  best  calculated  to  relieve  the  capillary  engorgement. 

IClcvation  is  not  only  a  valualjle  hemostatic  agent  in  preventing 
and   arresting    hemorrhage    from   the   vessels    of   the   extremities, 


64  PROPHYLACTIC    HEMOSTASIS. 

but  it  can  also  be  resorted  to  with  advantage  in  the  treatment  of 
wounds  or  in  operations  upon  the  skull  and  pelvis.  Elevation  of 
the  head  has  a  potent  influence  in  diminishing  the  blood  supply  to 
the  scalp  and  cranial  contents,  and  is  always  resorted  to  in  per- 
forming operations  upon  the  skull.  Trendelenburg's  position  is  a 
valuable  prophylactic  hemostatic  resource  in  operations  upon  the 
pelvic  organs.  The  same  degree  of  elevation  with  the  body  in  the 
ventral  position  should  be  made  use  of  in  extirpating  the  rectum,  as 
it  exerts  a  marked  influence  in  minimizing  venous  hemorrhage. 

Elastic  Constriction. — Some  form  of  elastic  constriction  is  now 
generally  practised  in  rendering  bloodless  the  part  that  is  injured  or 
that  is  to  be  operated  upon.  As  is  the  case  with  nearly  all  great 
discoveries,  attempts  in  the  same  direction  foreshadowed  the  labors 
of  von  Esmarch,  but  it  required  the  genius  and  influence  of  that  dis- 
tinguished surgeon  to  perfect  the  procedure  and  to  give  it  a  permanent 
and  wide  place  in  the  practice  of  surgery.  Elastic  constriction  in 
some  form,  in  preventing  or  arresting  hemorrhage  in  the  treatment 
of  wounds  and  the  operative  removal  of  diseased  tissues,  is  so 
simple  and  so  satisfactory  a  procedure,  and  the  means  required  are 
so  accessible,  that  it  is  now  in  almost  universal  use,  and  the  different 
forms  of  tourniquets  heretofore  employed  for  the  same  purpose  are 
for  good  and  substantial  reasons  regarded  by  the  modern  surgeons 
as  objects  of  antiquity. 

In  1852  Clover  was  on  the  very  verge  of  being  the  inventor  of 
bloodless  surgery.  In  a  case  of  hip-joint  amputation,  Joseph  Bell 
rendered  the  limb  to  be  removed  bloodless  by  elevation  and  elastic 
compression,  and  for  the  purpose  of  temporarily  displacing  a  large 
volume  of  blood  from  the  general  circulation,  brought  the  oppo- 
site limb  into  a  hanging  position  and  made  circular  constriction  at 
its  base.  He  applied  the  circular  constriction  on  the  wrong  side, 
according  to  the  practice  at  the  present  time.  The  constrictor  was 
tightened  only  sufficiently  to  obstruct  the  venous  circulation,  so  as 
to  exclude  temporarily  as  much  blood  as  possible  from  the  general 
circulation.  At  the  completion  of  the  operation  the  patient's  pulse 
became  feeble,  but  improved  on  removing  the  constriction  and  on 
the  return  of  the  excluded  blood  into  general  circulation.  A  very 
ordinary  case  led  von  Esmarch  to  devise  elastic  constriction  as  a 
prophylactic  hemostatic  resource.  The  case  was  one  of  acute  swel- 
ling of  a  finger  caused  by  the  wearing  of  a  finger-ring.  With  a 
strong  thread  he  made  compression  below  the  constriction,  winding 
the  thread  tightly  around  the  finger  from  its  tip  as  far  as  the  ring, 
placing  the  turns  close  to  one  another,  and  then  passed  the  thread 
through  the  ring,  and,  on  making  traction  laterally,  removed  the 
ring  without  any  difficulty. 

When  elastic  constriction  was  first  introduced  as  an  aid  to  the 
surgeon,  its  inventor  aimed  at  rendering  the  tissues  on  the  distal 
side  of  the  constrictor  perfectly  bloodless  by  applying  compression 
with  an  elastic  bandage  from  the  periphery  of  the  limb  to  the  point 


ELASTIC    CONSTRICTION.  65 

of  constriction.  This  part  of  the  technic  of  "  bloodless  "  operating 
is  not  onh'  unnecessary,  but  harmful.  It  has  been  shown  that 
under  a  justifiable  degree  of  compression  the  part  can  not  be  rendered 
absolutely  bloodless.  P.  Bruns  made  careful  experiments  to  deter- 
mine the  amount  of  blood  contained  in  an  extremity  after  ampu- 
tation under  elastic  constriction  without  elastic  compression.  He 
found  that  the  leg  and  foot  of  an  adult  only  contained  146  c.c.  of 
blood.  If  elastic  compression  is  used,  about  70  per  cent,  of  this 
amount  is  saved.  The  cases  are  therefore  exccf)tional  in  which  the 
surgeon  should  resort  to  elastic  compression  for  the  purpose  of 
saving  so  small  a  quantity  of  blood.  Besides,  elastic  compression 
employed  in  the  operative  treatment  of  a  recent  injury  or  of  an 
infective  inflammation  might  force  pathogenic  microbes  from  the 
wound  or  the  inflammatory  focus  into  the  general  circulation,  thus 
adding  a  general  to  a  local  infection,  with  all  the  additional  risks 
incident  to  such  a  condition.  In  operations  for  malignant  disease — 
carcinoma  or  sarcoma — it  might  force  tumor-cells  into  the  surround- 
ing tissues,  or  through  the  lymphatics  or  blood-vessels  into  the 
general  circulation,  thus  causing  local,  regional,  or  general  dissemi- 
nation of    the    disease.      These    two    sources    of   danger    are    not 


Fig.  21.  —  Esmarch's  method  of  applying  elastic  constriction. 

imaginary,  but  real,  and  every  surgeon  with  a  large  experience  can 
recall  instances  in  which  elastic  compression  could  be  made  answer- 
able for  the  diffu.sion  of  an  inflammatory  process  or  the  dissemina- 
tion of  malignant  disease.  Fortunately,  Lister's  experiments  on 
the  horse  have  demonstrated  that  for  all  practical  purposes  blood- 
less operations  can  be  made  without  the  use  of  the  elastic  bandage 
by  .simply  holding  the  limb  in  a  vertical  position  for  a  few  minutes 
prior  to  the  application  of  the  elastic  constrictor.  Exceptions  to 
this  rule  are  furni.shcd  by  operations  for  large  aneurysms  subjected 
to  treatment  by  excision,  where  ela.stic  compression,  if  it  can  be 
made  use  of,  will  become  the  means  of  .saving  a  large  amount  of 
blood  and  will,  in  addition,  facilitate  every  step  of  the  operation. 
Ordinarily,  the  necessary  degree  of  bloodle.ssness  is  secured  by 
holding  the  limb  in  a  perpendicular  position  for  five  minutes,  when 
elastic  constriction  is  applied  above  the  part  to  be  subjected  to 
operative  interference.  If  an  anesthetic  is  u.sed,  elevation  of  the 
limb  and  the  application  of  the  ela.stic  constrictor  should  not  be  done 
before  the  patient  is  thoroughly  under  the  influence  of  the  anes- 
thetic, as  muscular  relaxation  is  a  material  aid  in  bringing  about 
5 


66 


PROPHYLACTIC    HEMOSTASIS. 


the  desired  degree  of  local  anemia.  Local  anemia  can  be  further 
increased  by  rubbing  the  limb  firmly  in  the  direction  ot  the  venous 
current. 

The  Elastic  Constrictor  and  its  Application. — Elastic  constric- 
tion of  the  fingers,  toes,  and  penis  can  be  made  efficiently  and  safely 
by  using  elastic  bands,  such  as  are  for  sale  by  stationers.  Two  or 
three  turns  of  the  band  are  ample,  and  instead  of  tying  it  in  a  knot 
or  loop  it  is  much  better,  when  the  necessary  degree  of  constriction 
has  been  reached,  to  cross  the  band  and  apply  a  pair  of  hemostatic 

forceps  at  the 
point  of  crossing. 
In  constricting  the 
limbs  above  the 
base  of  the  fin- 
gers and  toes  Es- 
march's  constric- 
tor is  the  one 
usually  employed. 
It  consists  of  a 
strong  band  of 
rubber  an  inch  in 
width,  on  one  end 
of  which  is  at- 
tached a  chain 
and  on  the  other 
a  hook.  Some 
surgeons  have 
been  in  the  habit 
of  using  a  small, 
solid-rubber  cord 
or  rubber  tubing 
of  small  size  as 
an  elastic  tourni- 
quet. Both  of 
these  forms  of 
elastic  constrictor 
are  objectionable, 
as  in  either  in- 
stance linear  con- 
striction is  made,  which,  particularly  if  the  force  employed  be  ex- 
cessive, as  is  so  often  the  case,  is  so  liable  to  cause  temporary  or 
even  permanent  damage  to  some  of  the  important  tissues  interposed 
between  the  skin  and  the  underlying  unyielding  bone.  The  com- 
pression should  cover  a  surface  at  least  two  inches  wide,  in  order 
to  distribute  the  pressure  over  a  larger  area,  in  which  event  impor- 
tant structures  are  more  likely  to  escape  injury. 

Aside  from  Esmarch's  constrictor,  the  best  elastic  tourniquet 
consists  of  a  strong  band  of  rubber-webbing  bandage  at  least  two 


Fig.  22. — Proper  method  of  applying  the  elastic  constrictor. 


ELASTIC    CONSTRICTION. 


67 


inches  in  width,  of  which  never  fewer  than  two  turns  are  appHed 
side  by  side.  In  the  absence  of  such  material  a  soft-rubber  tube 
one-half  an  inch  in  diameter,  an  ordinary  rubber  bandage,  or  an 
elastic  suspender  should  be  used.  The  constrictor  should  be 
applied  at  a  point  where  the  large  nerve-trunks  are  amply  protected 
by  a  thick  cushion  of  muscle  tissue — that  is,  near  the  base  of  the 


Fig.  23. — Elastic  con- 
striction of  upper  extrem- 
ity (after  SeydelJ. 


Fig.   24. — Elastic  constriction  of  lower  extremity 
(after  Seydel). 


Fig.  25. — Elastic  constriction  of  thigh 


Elastic  constriction  of 
finger. 


limbs.  As  soon  as  the  limb  has  been  drained  of  its  blood  to  the 
requisite  extent  by  position  and  mas.sage,  the  constrictor  is  applied 
with  sufficient  firmness  to  interrupt  at  once  both  the  arterial  and 
venous  circulations.  Simj)lc  as  this  advice  may  sound,  it  is  never- 
theless true   that  frequent  mistakes  are  made  in  properly  applying 


68 


PROPHYLACTIC    HEMOSTASIS. 


the  constrictor,  even  in  well-i-egulated  clinics.  The  hmb  must  be 
held  immovably  by  an  assistant  (Fig.  22).  The  middle  of  the  con- 
strictor is  applied  where  constriction  is  first  to  be  made,  and  is 
grasped  with  the  forearms  crossed  in  such  a  manner  that  the  two 
hands  are  not  more  than  four  inches  apart.  It  is  of  the  utmost 
importance  that  the  pressure  should  first  be  made  on  the  side  of 
the  limb  where  the  principal  blood-vessels  are  located.  If  pressure 
is  made  first  on  the  opposite  side  of  the  limb,  the  superficial  veins 
are  constricted  first,  and  before  the  arterial  circulation  is  interrupted 
the  limb,  when  fully  constricted,  presents  a  cyanotic  appearance, 
caused  by  an  intense  passive  venous  stasis.  If,  on  the  other  hand, 
the  elastic  pressure  is  applied  in  such  a  manner  as  to  intercept  the 
principal  arterial  blood  supply  first,  venous  return  in  the  superfi- 
cial veins  is  not  interfered  with  until  the  circular  constriction  is 

completed,  and  the  limb  below  the 
constriction  is  then  comparatively 
bloodless,  and  remains  so  after  the 
application  of  the  constrictor. 

Some  tact  and  experience  are 
necessary  in  determining  the  force 
required  to  interrupt  quickly  and 
completely  the  arterial  and  venous 
circulations.  Elastic  pressure  is  de- 
ceptive, and  it  is  much  more  fre- 
quently the  case  that  too  much  pres- 
sure is  made  than  the  reverse.  Less 
force  is  required,  of  course,  when  the 
main  blood-vessels  are  near  the  sur- 
face and  close  to  a  bone  than  when 
a  thick  layer  of  muscles  is  interposed 
between  skin  and  blood-vessels,  or 
between  blood-vessels  and  the  under- 
lying bone.  Pressure  beyond  the  re- 
quired degree,  especially  if  continued 
for  an  hour  or  more,  is  liable  to  result 
in  injury  of  muscles  and  nerves,  and  should  be  carefully  avoided. 
Instead  of  using  the  chain  or  tying  the  constrictor  in  a  knot  it  is 
better,  after  encircling  the  limb  at  least  twice,  to  cross  the  constric- 
tor and  fasten  it  between  the  blades  of  a  heavy  hemostatic  forceps. 
For  how  long  is  it  safe  to  exclude  the  circulating  blood  from  a 
limb  by  elastic  constriction  ?  This  is  an  exceedingly  important 
practical  question.  Clinical  experience  can  not  be  relied  upon 
exclusively  in  giving  a  satisfactory  answer.  There  are  cases  on 
record  in  which  elastic  constriction  in  accident-cases  was  continued 
for  from  seven  to  twelve  hours  without  having  caused  gangrene, 
but  the  cases  are  more  numerous  in  which  a  much  shorter  period 
of  elastic  constriction  has  resulted  disastrously.  The  danger  of 
gangrene  from  elastic  constriction  is,  of  course,  much  greater  when 


Fig.   27. — Suspender  constriction  of 
arm. 


ELASTIC    CONSTRICTION. 


69 


employed  for  the  purpose  of  arresting  traumatic  hemorrhage  than 
when  used  as  a  prophylactic  hemostatic  in  the  operative  treatment 
of  chronic  affections.  Unimpaired  general  health  and  normal  blood- 
vessels are  conditions  most  compatible  with  the  safety  of  prolonged 
constriction.  With  a  view  to  throwing  additional  light  on  the  ele- 
ment of  time  in  the  use  of  elastic  constriction  I  made,  a  number 
of  years  ago,  sixteen  experiments  on  dogs.  The  exclusion  of  the 
circulating  blood  from  the  limb  below  the  constriction  was  abso- 
lute in  eveiy  instance.  The  constriction  was  made  either  above 
the  elbow-  or  the  knee-joint.  It  was  made  with  rubber  tubing  a 
quarter  of  an  inch  in  diameter,  with  which  the  limb  was  encircled 
at  least  twice,  and  tied  with  sufficient  firmness  to  interrupt  both  the 

arterial  and  the  venous  circulation  com- 
pletely. As  the  constriction  appeared 
to  produce  considerable  pain,  the  ani- 
mals were  kept  fully  under  the  influence 
of  morphin,  which  was  administered  sub- 
cutaneousl)',  usually  in  divided  doses. 
The  length  of  time  the  constriction  was 


Fig.  28. — Von  Esmarch's  elastic  constrictor,  with  strap  and  cliain. 


continued  varied  from  two  hours  and  a  half  to  twenty-six  hours. 
Only  in  one  case  did  the  experiment  result  in  gangrene  : 

"  Medium-sized  female  dog  ;  constricted  May  9th,  8.40  a.m. 
Constriction  above  elbow  by  three  turns  of  tubing  tightly  drawn  and 
tied.  Removed  May  loth,  1. 10  a.m.  Time  of  constriction,  .seven- 
teen hours.  Palm  incised  before  removal  of  constrictor  ;  yields  a 
little  dark,  fluid,  venous  blood.  In  ten  minutes  blood  becomes 
somewhat  lighter  in  color,  but  does  not  flow  freely.  In  twenty 
minutes  pulse  could  be  detected,  but  was  very  indistinct.  Leg 
greatly  swollen  ;  soft  parts  appeared  to  be  nearly  divided  subcuta- 
neou.sly  at  point  of  con.striction.  One  and  one-third  grains  of 
morphin  injected  in  divided  doses. 

"  May  I  ith,  swelling  of  limb  the  same. 

"May  14th,  swelling  stationary;  entirely  useless;  begins  to 
show  discoloration. 

"May  15th,  gangrene  complete." 

The  experiments  demonstrated  sufficiently  that  in  most  of  the 


yo  PROPHYLACTIC    HEMOSTASIS. 

animals  where  constriction  was  continued  for  more  than  three  hours 
the  hmb  was  either  useless  or  the  animal  walked  lame  for  a  number 
of  days.  This  temporary  disability  of  the  limb  was  undoubtedly 
occasioned  not  by  pain,  but  by  injury  to  the  constricted  muscles. 
In  the  case  in  which  loss  of  function  was  continued  for  several 
weeks  there  can  be  but  very  little  doubt  that  the  pressure  produced 
at  the  same  time  a  nerve-lesion,  retarding  recovery  until  a  sufficient 
time  had  elapsed  for  regeneration  of  the  nerve  to  have  taken  place. 
In  the  median  nerve  removed  after  the  experiment  in  which  the  con- 
striction was  continued  for  twenty  hours,  the  essential  histologic 
nerve  elements  at  the  point  of  constriction  could  not  be  identified, 
and  the  nerve-fibers  on  the  distal  side  showed  all  the  appearances 
of  far-advanced  degeneration.  The  animal  which  was  subjected  to 
constriction  for  the  longest  time — twenty-six  hours — recovered  full 
use  of  the  limb  after  the  lapse  of  six  weeks. 

Temporary  loss  of  muscular  power  and  nerve  paralysis  result- 
ing from  elastic  constriction  are,  undoubtedly,  often  the  direct  out- 
come of  a  faulty  application  of  the  constrictor,  improper  selection 
of  the  point  of  constriction,  or  excessive  pressure.  The  experi- 
ments referred  to  show  conclusively  that  firm  constriction,  con- 
tinued for  several  hours,  almost  invariably  results  in  diminution  or 
suspension  of  the  function  of  the  limb,  which  does  not  disappear 
for  several  days  or  weeks. 

Functional  disturbances  that  yielded  in  the  course  of  a  few  days 
were  undoubtedly  due  to  muscle  injury.  If  in  the  use  of  the  con- 
strictor more  force  is  applied  than  is  necessary  to  interrupt  the  cir- 
culation, and  particularly  if  linear  pressure  is  made,  injury  of  the 
muscles  exposed  to  this  undue  pressure  is  very  likely  to  be  pro- 
duced. The  same  can  be  said  of  injury  to  the  nerves  from  a 
similar  cause.  Of  several  cases  of  nerve  paralysis  which  occurred 
in  my  practice,  the  two  following  were  typical  in  every  respect : 

The  first  case  was  a  young  man  who  was  the  subject  of  necrosis 
of  the  radius.  Elastic  constriction  was  made  just  above  the  elbow- 
joint,  and  at  a  point  where  the  musculospiral  nerve  is  almost  sub- 
cutaneous. The  operation  lasted  about  an  hour.  The  next  day  it 
was  noticed  that  the  patient  was  unable  to  extend  the  hand.  The 
function  of  the  nerve  was  destroyed  as  completely  as  though  it  had 
been  divided.  Massage  and  electricity  were  employed  at  the  end 
of  the  second  week,  but  no  signs  of  improvement  were  observed 
before  the  expiration  of  two  months,  and  function  was  not  fully 
restored  at  the  end  of  three  months.  During  this  time  muscular 
atrophy  was  noticeable.  With  the  restoration  of  nerve  function 
muscular  nutrition  set  in,  and  eventually  the  use  of  the  hand  and 
forearm  was  restored  to  perfection. 

The  second  case  was  a  student  suffering  from  extensive  necrosis 
of  the  tibia.  Elastic  constriction  was  applied  just  above  the  knee- 
joint.  The  disease  involved  nearly  the  entire  shaft  of  the  tibia. 
The  skin-flaps  were  turned  inward  into  the  deep  gutter  and  fastened 


ELASTIC    CONSTRICTION.  7 1 

with  aseptic  bone-nails.  The  margins  of  the  flaps  necrosed,  and  the 
extensive  cutaneous  defect  was  replaced  by  a  slow  process  of  gran- 
ulation, cicatrization,  and  epidermization  tliat  required  several  months 
to  complete  the  healing  process.  Soon  after  the  operation  it  became 
apparent  that  the  function  of  the  peroneal  nerve  had  been  destroyed 
by  the  elastic  constriction.  Electricity  and  massage  proved  of  no 
avail  in  restoring  nerve  function,  as  the  paralysis  remained  com- 
plete two  years  after  the  operation.  I  have  reason  to  believe  that 
if  the  elastic  constriction  in  these  cases  had  been  made  at  the  base 
of  the  limbs  instead  of  at  the  localities  mentioned,  in  all  probability 
the  nerve  injury  might  have  been  avoided. 

With  a  view  to  preventing  injurious  pressure  on  important 
nerves  from  elastic  constriction  it  is  necessary  to  constrict  only  with 
sufficient  firmness  to  interrupt  the  arterial  and  venous  circulations. 
Moreover,  the  pressure  should  not  be  linear,  but  distributed  over  a, 
circle  at  least  two  to  four  inches  in  width.  The  last  requirement  is 
best  attained  by  using  a  wide  band,  or  if  an  elastic  tube  or  cord  is 
used,  the  limb  should  be  encircled  several  times,  each  turn  drawn 
with  uniform  force  and  arranged  in  such  a  manner  as  to  compress 
with  equal  firmness  a  wide  circle,  thus  exerting  the  same  effect  on 
the  tissues  underneath  as  pressure  made  by  a  wide  band.  If,  for 
any  reason,  the  constriction  can  not  be  made  at  a  point  where  the 
principal  nerves  are  well  protected  by  a  thick  layer  of  muscles,  a 
thick  compress  of  gauze  should  be  placed  between  the  constrictor 
and  the  limb,  in  order  to  protect  the  nerves  against  injurious  pres- 
sure. From  the  foregoing  it  may  be  inferred  that  it  would  not  be 
safe  to  continue  elastic  constriction  for  more  than  three  or  four  hours 
in  the  treatment  of  accidental  hemorrhage.  The  question  of  time  is 
an  important  matter,  more  especially  to  the  military  and  the  railway 
surgeon.  In  emergency  cases  we  must  calculate  the  time  when 
we  are  in  a  position  to  substitute  for  elastic  constriction  more  direct 
measures  for  the  arrest  of  hemorrhage. 

In  the  u.se  of  Esmarch's  constrictor  in  arresting  hemorrhage 
that  threatens  life,  more  especially  on  the  battle-field,  it  is  not  neces- 
sary to  distinguish  between  venous  and  arterial  hemorrhage.  It 
was  the  con.sensus  of  opinion  of  the  members  of  the  military  section 
of  the  Berlin  International  Medical  Congress  that  it  is  no  longer 
wise  nor  practical  to  differentiate  between  arterial  and  xenons  hemor- 
rhage in  rendering  the  first  aid  to  the  wounded  on  the  battle-field 
or  in  a  case  of  accidental  hemorrhage  elsewhere  ;  that  the  one  [)()int 
that  must  be  taught  the  soldier,  the  brakeman,  and  the  conductor 
is  that,  if  hemorrhage  is  so  profuse  as  to  threaten  life  before  medical 
aid  can  be  summoned,  it  should  be  at  once  arrested  by  elastic  con- 
striction,— by  a  suspender  if  nothing  else  is  at  hand, — applied 
invariably  on  the  proximal  side  of  the  seat  of  injury. 

1  he  constriction  must  be  made  with  sufficient  firmness  to  arrest 
completely  both  the  arterial  and  venous  circulations,  as  has  been 
repeatedly  emphasized.       By  applying    the    constrictor  with   just 


72  PROPHYLACTIC    HEMOSTASIS. 

sufficient  firmness  to  diminish  the  arterial  circulation  without  inter- 
rupting it,  the  venous  hemorrhage  is  increased.  It  is  by  overload- 
ing the  tissues  with  venous  blood  by  imperfect  constriction  that 
gangrene  is  invited  and  venous  hemorrhage  increased.  Experi- 
mental research  has  shown  that  an  ischemic  condition  and  elastic 
constriction  for  two  hours  or  moi'e  are  liable  to  produce  an  unfavor- 
able influence  on  the  karyokinetic  process  in  the  tissues  deprived 
of  blood  for  that  length  of  time.  This  is  a  sufficient  proof  that 
prolonged  constriction  retards  the  healing  process.  Necrobiosis, 
slow  healing,  and  necrosis  of  the  margins  of  the  wound  are  some 
of  the  remote  consequences  which  follow  prolonged  constriction 
of  a  limb.  A  well-recognized  disadvantage  of  elastic  constriction 
as  a  hemostatic  measure  is  increased  parenchymatous  hemorrhage. 
The  profuse  capillary  oozing  which  so  often  follows  the  removal  of 
.the  constrictor  is  undoubtedly,  at  least  in  part,  due  to  a  temporary 
vasomotor  paresis  caused  by  the  constriction.  This  result  is  min- 
imized most  successfully  by  keeping  the  limb  in  an  elevated  posi- 
tion at  the  time  the  constrictor  is  removed,  and  by  maintaining  the 
vertical  position  without  interruption  for  at  least  six  hours.  The 
intravascular  tension  is  reduced  to  a  minimum  by  elevation  of  the 
limb,  and  this  condition  is  most  conducive  to  the  formation  of  a 
minute  thrombus  in  each  of  the  small  vessels,  capillaries,  arteries, 
and  veins  cut  during  the  operation. 

Another  exceedingly  useful  resource  in  diminishing  unnecessary 
loss  of  blood,  after  all  visible  vessels  have  been  tied  and  the  con- 
strictor has  been  removed,  consists  in  making  firm  pressure  against 
the  wound  surface.  This  can  be  most  effectually  done  by  using  a 
gauze  compress  wrung  out  of  a  hot  normal  salt  solution,  which  is 
firmly  held  against  the  wound  with  one  or  both  hands.  After  an 
amputation,  for  instance,  all  the  principal  vessels  should  be  sought 
for  and  tied  before  the  constrictor  is  removed,  and  the  limb  held  in 
a  vertical  position.  A  compress  is  then  placed  against  the  wound 
surface,  the  flaps  brought  over  it,  and  firm  compression  made  over 
the  end  of  the  stump  with  both  hands  for  at  least  five  minutes. 
The  compress  is  then  lifted  away,  and  spurting  points  are  caught 
with  hemostatic  forceps  and  tied.  In  obstinate  cases  an  application 
of  peroxid  of  hydrogen  serves  an  excellent  hemostatic  purpose,  and 
does  not  interfere  with  primary  healing  of  the  wound.  The  impor- 
tance of  a  recourse  to  prophylactic  hemostatic  measures  is  propor- 
tionate to  the  size  and  number  of  the  blood-vessels  which  must 
unavoidably  be  severed  in  an  operation.  Thus,  in  amputation  of 
the  extremities,  without  special  precautions,  the  immediate  risk  to 
life  from  hemorrhage  is  greater  the  nearer  the  amputation  approaches 
the  trunk.  While  a  finger,  a  toe,  or  even  a  hand  or  a  foot  might 
be  amputated  without  the  use  of  a  tourniquet  or  elastic  constrictor 
without  incurring  any  immediate  risk  to  life  from  the  loss  of  blood, 
such  a  procedure  in  amputation  at  the  shoulder-joint  or  hip-joint 
would  jeopardize  life  on  the  operating  table. 


ELASTIC    CONSTRICTION.  y^ 

The  general  condition  and  age  of  the  patient  have  their  influ- 
ence in  determining  the  necessity  for  a  resort  to  the  most  pains- 
taking prophylactic  hemostatic  precautions.  The  healthy  and  ro- 
bust tolerate  the  loss  of  blood  much  better  than  patients  worn  out 
by  disease  or  deprivations  or  excesses  of  any  kind.  The  subjects 
of  acute  septic  processes  are  peculiarly  liable  to  suffer  severely  from 
the  loss  of  any  considerable  amount  of  blood.  Infants,  children, 
and  the  aged  do  not  bear  the  loss  of  blood  so  well  as  young  adults 
and  persons  of  middle  age,  and  hence  when  injured  or  subjected 
to  operative  intervention,  special  precautions  must  be  employed  in 
guarding  against  the  loss  of  blood.  Elastic  constriction  has  been 
applied  to  different  parts  of  the  body  where  constriction,  as  de- 
scribed above,  would  be  impracticable. 

Special  Localities  for  Elastic  Constriction  as  a  Prophylactic 
Hemostatic. — In  variously  modified  forms  the  great  principle  of 
elastic  constriction  as  a  prophylactic  hemostatic  resource  has  been 
applied  over  the  entire  surface  of  the  body  and  many  of  the  inter- 
nal organs  when  the  seat  of  direct  operative  interference.  Vascular 
tumors  and  operations  on  the  gastro-intestinal  canal  and  uterus 
furnish  familiar  examples.  In  all  injuries  and  operations  upon  the 
extremities  below  the  shoulder-  and  hip-joints  we  have  now  in 
Esmarch's  elastic  constrictor,  or  any  of  its  substitutes,  a  reliable 
measure  with  which  we  can  absolutely  control  hemorrhage  tem- 
porarily and  thus  minimize  the  loss  of  blood.  In  disarticulation  at 
the  hip-  and  shoulder-joints  it  must  be  modified  to  adapt  itself  to 
the  anatomic  conformation  of  the  respective  localities. 

Hip=joint. — The  various  attempts  made  in  the  past  to  control 
hemorrhage  in  amputations  at  the  hip-joint  furnish  material  for  an 
interesting  and  useful  study.  We  must  be  free  to  admit  that  this  sub- 
ject constitutes  by  no  means  a  closed  chapter.  The  first  attempts 
were  directed  toward  rendering  the  limb  bloodless  by  compression 
of  the  aorta  near  its  bifurcation.  Tourniquets  for  this  purpose  were 
invented  by  Pancoast,  Esmarch,  Syme,  Tiemann,  Signorini,  Lister, 
and  Brandis.  This  method  of  rendering  the  operation  bloodless  is 
uncertain,  as  the  compressor  may  become  displaced  during  sudden 
movements  of  the  patient.  Further,  it  is  open  to  the  serious  objec- 
tion that,  when  efficiently  applied,  it  cuts  off  the  arterial  circulation 
from  nearly  one  half  of  the  body,  a  circumstance  attended  by  no 
inconsiderable  immediate  risk  to  life  from  sudden  vascular  engorge- 
ment of  im[)ortant  internal  organs.  In  several  cases  in  which  this 
in.strument  was  u.scd  severe  venous  hemorrhage  was  encountered. 
An  additional  objection  to  the  employment  of  this  instrument  is 
the  fact  that  organs  interposed  between  the  abdominal  wall  and  the 
spine,  against  which  the  {pressure  is  made,  maybe  injured.  Digital 
compression  of  the  femoral  or  external  iliac  artery,  a  method  of 
controlling  hemorrhage  inaugurated  by  Abernethy,  is  unreliable,  as 
fingers  are  very  apt  to  slip  during  the   manipulation   of  the  limb, 


74  PROPHYLACTIC    HEMOSTASIS. 

and  in  that  it  does  not  cut  off  the  blood  supply  from  the  remaining 
large  arterial  trunks  of  the  limb. 

The  next  step  in  the  development  of  the  technic  of  bloodless 
amputation  at  the  hip-joint  was  devised  by  Mr.  Davy,  and  consists 
in  instrumental  compression  of  the  common  iliac  artery  against  the 
pelvic  brim.  The  instrument  consists  of  a  smooth  rod  or  cylinder 
of  hard  wood  or  metal,  from  eighteen  to  twenty-five  inches  in  length, 
and  terminating  in  a  conic  blunt  extremity.  The  directions  given 
for  the  use  of  this  instrument  are  the  following  :  "  Oil  having  been 
injected  into  the  bowel,  the  conic  or  larger  end  of  the  lever  is  intro- 
duced into  the  rectum,  and  is  passed  in  the  direction  of  the  vessel 
to  be  compressed.  The  surgeon,  feeling  the  end  of  the  instrument 
through  the  abdominal  wall,  directs  it  to  the  common  iliac  as  it  lies 
on  the  pelvic  brim.  The  handle  of  the  instrument  is  now  carried 
to  the  thigh  of  the  opposite  side,  and  is  then  raised  so  that  it  may 
act  as  a  lever,  for  which  the  anus  serves  as  a  fulcrum."  This 
method  is  not  only  unreliable,  but  is  inapplicable  in  cases  where  no 
mesorectum  exists,  and  has  more  than  once  caused  serious  damage 
to  the  bowel.  For  these  reasons  it  was  never  generally  adopted 
and  has  now  fallen  into  well-merited  disuse. 

Preliminary  ligation  of  the  common  femoral  artery  was  advo- 
cated by  von  Volher,  Puthod,  Moublet,  Larrey,  Delpech,  Orten,  A. 
Cooper,  Blandin,  Velpeau,  Roser,  Roux,  and  Boyer.  Von  Volher, 
Larrey,  and  Roser  tied,  at  the  same  time,  the  femoral  vein.  Scul- 
tetten  proposed  preliminary  ligation  of  the  external  iliac  artery. 
Against  preliminary  ligation  were  arrayed  Lalouette,  Abernethy,  B. 
Bell,  Richter,  Guthrie,  Baffos,  Langenbeck,  S.  Cooper,  Pelikan,  Be- 
clard,  Dupuytren,  von  Walther,  Krimer,  Bryce,  and  Lenoir.  Prelimi- 
nary ligation  of  the  femoral  vessels  and  digital  compression  do  not 
render  the  operation  sufficiently  bloodless,  and  can  not  be  relied  upon 
in  cases  in  which  the  loss  of  several  ounces  of  blood  would  imperil 
the  life  of  the  patient.  Pirogoff,  von  Pitha,  and  Volkmann  advised 
ligation  of  the  principal  vessels  in  the  incisions  made  in  forming 
the  flaps,  prior  to  their  division.  Out  of  39  cases  of  preliminary 
ligation  1 1  died,  while  of  29  treated  by  digital  compression  17  recov- 
ered, showing  that  the  former  procedure  is  less  effective  than  digital 
compression.  In  three  cases  the  profunda  had  a  high  origin,  and 
the  object  of  the  preliminary  ligation  was  not  fully  realized.  Lin- 
hart  lost  one  case  by  hemorrhage  from  the  branches  of  the  hypo- 
gastric artery.  Beck  had  a  death  from  secondary  hemorrhage  at 
the  point  of  ligation.  E.  Rose  does  not  rely  on  digital  compression, 
preliminary  ligation  of  the  common  femoral,  or  constriction,  but  ties 
each  vessel  twice  before  cutting  it.  This  method  requires  more  time 
than  it  is  prudent  to  allow  for  the  performance  of  an  operation 
which  is  attended  by  so  much  risk  from  shock.  Pean  operated  in 
a  somewhat  similar  manner,  but  relied  on  hemostatic  forceps  instead 
of  ligatures  to  control  the  bleeding  during  the  operation,  which  saves 
much  valuable  time.      Soon  after  the  introduction  by  von  Esmarch 


ELASTIC    CONSTRICTION. 


75 


of  the  bloodless  method  of  operating  by  elastic  constriction,  it  was 
applied  b}'  this  surgeon,  in  a  modified  form,  to  disarticulation  at  the 
hip-joint.      He  gave  the  following  original  directions  : 

"  In  high  amputations  of  the  thigh  the  tube  is  tightly  wound 
once  or  twice  around  the  limb,  just  below  the  flexure  crease  of  the 
thigh,  the  ends  are  crossed  above  the  groin,  passing  around  over 
the  posterior  surface  of  the  pelvis,  and  are  finally  hooked  together 
by  the  chain  across  the  abdomen  (Fig.  24).  A  firmly  rolled  linen 
bandage  may  also  be  laid  over  the  iliac  artery,  directly  above 
Poupart's  ligament,  as  a  pad,  and  tightly  pressed  upon  the  artery 
by  several  figure-of-eight  turns  of  a  strong  rubber  bandage."  Mr. 
Jordan  Lloyd  employed  for  the  same  purpose  a  common  calico 
roller,  which  was  applied  over  the  external  iliac  artery,  over  which 
was  placed  a  strip  of  black  india-rubber  bandage  about  two  yards 
long,  which  was  doubled.  The  center  of  this  bandage  rested 
between  the  tuber- 
osity of  the  ischium 
and  the  anus,  and 
the  ends,  drawn 
tight  enough  to 
arrest  the  circula- 
tion completely, 
were  firmly  held 
at  a  point  corre- 
sponding to  the 
center  of  the  iliac 
crest  on  the  side  to 
be  operated  upon. 
In  order  to  prevent 
slipping  away  of 
the  band  from  the 
compress  the.se 
were  fastened  together  with  a  safety-pin.  By  this  method  of  com- 
pression Mr.  Lloyd  ex[)ected  to  prevent  hemorrhage  from  all  the 
ves.sels  on  a  level  with  the  hip-joint.  The  prevention  of  hemor- 
rhage by  this  method  rests  largely  in  the  hands  of  the  assistant, 
and,  consequently,  can  not  be  relied  upon  under  all  circumstances. 
In  disarticulation  of  the  thigh  through  an  external  or  anterior 
racket  incision,  elastic  constriction  as  heretofore  practised  has 
been  very  unsatisfactory  indeed,  and  main  reliance  was  placed  on 
dividing  the  tissues  quickly  after  disarticulation,  seizing  and  tying 
the  principal  vessels. 

One  great  ob.stacle  to  the  use  of  elastic  constriction  in  this 
operation  has  been  the  slii)ping  of  the  constrictor.  I'or  the  pur- 
pose of  preventing  this  accident  the  thigh  below  the  constrictor 
has  been  transfixed  by  long  needles  or  skewers.  Trendelenburg 
transfixes  the  thigh  by  a  single  stout  steel  needle  passed  in  front 
of  the   neck    of  the   femur  and   beneath   the   large   ves.sels.      Mr. 


Fig.  29. — Wyeth's  bloodless  amputation  at  the  hip- 
joint  ;  the  pins  and  rubber  tubing  applied ;  circular  and 
longitudinal  incisions  for  skin-flap. 


^6  PROPHYLACTIC    HEMOSTASIS. 

Myles  thrusts  a  steel  skewer  straight  through  the  thigh  from  before 
backward.  The  needle  is  made  to  enter  just  below  Poupart's 
ligament,  and  to  the  outer  side  of  the  femoral  artery  it  passes  to 
the  inner  side  of  the  neck  of  the  femur,  and  emerges  a  httle  above 
the  gluteal  fold.  A  rubber  cord  in  the  form  of  a  figure-of-eight  is 
passed  around  the  projecting  ends  of  the  skewer.  Wyeth  uses 
two  strong  mattress  needles  to  prevent  slipping  of  the  constrictor. 
The  point  of  one  is  inserted  an  inch  and  a  half  below,  and  to 
the  inner  side  of,  the  anterior  superior  spinous  process  of  the  ilium, 
and  is  made  to  traverse  the  muscles,  passing  about  half-way  between 
the  great  trochanter  and  the  iliac  spine,  external  to  the  neck  of  the 
femur,  and  emerging  from  just  behind  the  trochanter.      The  second 


- 

,-:  / 

- '  i^ 

1    :', 

^  .-■•  .*:■■;'; 

^ 

'- "~ 

y 

Fig.  30. — Wyeth' s  bloodless  amputation  at  the  hip-joint ;  cuff  of  skin  and  subcuta- 
neous fat  turned  back  ;  muscles  divided  at  level  of  small  trochanter ;  bone  partly  stripped, 
and  large  vessels  exposed  for  deligation. 

needle  is  entered  an  inch  below  the  level  of  the  groin,  internal  to 
the  saphenous  opening,  and  passes  through  the  adductors,  the 
point  coming  out  about  an  inch  and  a  half  in  front  of  the  tuber- 
osity of  the  ischium.  A  piece  of  strong  rubber  tubing,  one-half 
an  inch  in  diameter,  and  long  enough  when  tightened  to  go  five  or 
six  times  around  the  thigh,  is  now  wound  very  tightly  around  and 
above  the  fixation  needles  and  tied.  The  elastic  constrictor  and 
needles  are  removed  as  soon  as  the  circular  amputation  is  com- 
pleted and  the  principal  blood-vessels  have  been  tied,'  whereupon 
the  proximal  end  of  the  femur  is  removed  (Fig.  30). 

Wyeth's   method  of  controlling  hemorrhage  in  amputation  at 


ELASTIC    CONSTRICTION.  7/ 

the  hip-joint  has  had  an  extensive  trial,  particularly  in  this  country, 
and,  on  the  whole,  has  given  great  satisfaction.  To  me,  however, 
it  appears  immaterial  whether  one  or  two  needles  are  employed, 
as  the  object  of  their  use  is  simply  to  prevent  slipping  of  the  con- 
strictor, which  is  fully  accomplished  by  using  one  needle  or  skewer. 
Elastic  constriction,  as  just  described,  has  two  disadvantages  which 
detract  from  its  utility  in  emergency  surgery  :  ( i)  Needles  or  skewers 
are  not  always  at  hand  ;  (2)  enucleation  of  the  proximal  end  of  the 
femur  is  a  very  difficult  task,  owing  to  the  shortness  of  the  frag- 
ment. The  method  is  better  adapted  for  high  amputation  of  the 
thigh  than  for  disarticulation  at  the  hip- joint.  For  the  purpose  of 
further  simplifying  prophylactic  hemostasis  for  disarticulation  at  the 
hip-joint  I  have  modified  elastic  constriction,  which  narrows  the 
requirements  down  to  a  piece  of  rubber  tubing  long  and  strong 
enough  to  constrict  the  base  of  the  thigh  after  preliminary  disar- 
ticulation. The  cardinal  points  of  this  method  are  :  (i)  Preliminary 
dislocation  of  the  head  and  isolation  of  the  upper  portion  of  the 
femur  from  attached  soft  tissues  through  an  external  straight  in- 
cision ;  (2)  elastic  constriction  of  the  thigh  below  the  pelvis  until  am- 
putation has  been  completed  and  the  principal  vessels  have  been  tied. 
A  straight  incision  about  eight  inches  in  length  is  made  directly 
over  the  center  of  the  great  trochanter  and  parallel  to  the  long  axis 
of  the  limb,  extending  about  three  inches  above  the  upper  border 
of  the  great  trochanter.  When  the  knife  reaches  the  great  tro- 
chanter, its  point  should  be  kept  in  contact  with  the  bone  the  whole 
length  of  the  remaining  part  of  the  incision.  The  margins  of  the 
wound  are  now  retracted,  and  any  spurting  vessels,  such  as  the 
circumflex  arteries,  secured  by  apph'ing  pressure  forceps.  During 
this  and  the  remaining  steps  of  the  operation  the  body  is  drawn 
down  so  that  the  pelvis  rests  upon  the  lower  edge  of  the  table,  in 
order  that  the  thigh  can  be  manipulated  freely  by  the  assistant  who 
is  intrusted  with  this  work  (Fig.  31).  The  trochanteric  muscular 
attachments  arc  now  severed  clo.se  to  the  bone  with  a  stout  scalpel. 
The  clearing  of  the  digital  fossa  and  the  division  of  the  tendon  of 
the  obturator  extern  us  require  special  care.  The  thigh  is  now 
flexed,  strongly  adducted,  and  rotated  inward,  when  the  capsular 
ligament  is  divided  transversely  at  its  upper  and  posterior  aspect. 
The  remaining  portion  of  the  capsular  ligament  is  severed,  while 
the  thigh  is  brought  back  to  a  position  of  slight  flexion,  after  which 
it  is  rotated  outward,  and,  if  possible,  the  ligamentum  teres  is  cut.  If 
this  can  not  be  done,  the  head  of  the  bone  is  forcibly  dislocated 
upon  the  dorsum  of  the  ilium  by  flexion,  adduction,  and  rotation 
inward  of  the  thigh.  After  dislocation  has  been  effected,  the 
trochanter  minor  and  the  upper  part  of  the  shaft  of  the  femur  are 
cleared  by  using  scalpel  and  periosteal  elevator  alternately.  At 
the  completion  of  this  jiart  of  the  operation  the  femur  is  in  a  posi- 
tion of  extreme  adduction,  and  the  upper  portion  projects  some 
distance  from  the  surface  of  the  wound. 


78 


PROPHYLACTIC    HEMOSTASIS. 


During  the  operation,  so  far,  if  the  surgeon  has  kept  in  close 
contact  with  the  bone  and  has  used  the  knife  sparingly  and  the 
periosteal  elevator  freely,  the  hemorrhage  has  been  very  slight — 
much  more  so  than  if  this  part  of  the  operation  had  been  reserved 
for  the  last,  as  is  done  in  von  Esmarch's  and  Wyeth's  methods. 
Elastic  constriction  is  now  applied  in  the  following  manner  :  The 
limb  is  brought  down  in  a  straight  line  with  the  body,  the  thigh  is 
slightly  flexed  so  as  to  push  the  upper  free  end  of  the  femur  for- 
ward into  and  beyond  the  wound,  when  a  long  stout  hemostatic 


Fig.  31. — Senn's  method  of  performing  bloodless  amputation  at  the  hip-joint. 
Dislocation  of  head  of  femur  and  upper  portion  of  shaft  through  straight  external  inci- 
sion.    Elastic  constrictors  in  place,  the  anterior  one  tied. 


forceps  is  inserted  into  the  wound  behind  the  femur  and  on  a  level 
with  the  trochanter  minor  when  in  a  normal  position.  The  instru- 
ment is  then  pushed  inward  and  downward  two  inches  below  the 
ramus  of  the  ischium  and  just  behind  the  adductor  muscles.  As 
soon  as  the  pomt  can  be  felt  under  the  skin  in  this  location,  an 
incision  is  made  through  the  skin,  about  two  inches  in  length, 
through  which  the  instrument  is  made  to  emerge.  After  enlarging 
the  tunnel  made  in  the  soft  tissues  by  dilating  the  branches  of  the 
forceps,   a    piece  of  aseptic    rubber    tubing    three-quarters  of   an 


ELASTIC    CONSTRICTION. 


79 


inch  in  diameter  and  about  three  or  four  feet  in  length  is  grasped 
with  the  forceps  in  the  middle  and  is  drawn  along  the  tunnel  as  the 
forceps  are  withdrawn,  whereupon  the  rubber  tube  is  cut  in  two  at 
the  point  where  it  was   held  by  the  forceps.      With   one  half  of 


-Elastic  constriction  completed  by  constricting  the  posterior  segment  of  the 
thigh.      Flaps  formed  including  all  the  tissues  down  to  the  muscles. 


i'tJ-   33- — Stutni)  after  disarticulation   at   the   lii|)-joint.      Long  ])osterior  cutaneous  flap 
(Clinic,  Rush  Medical  College). 

the  tube  the  anterior  segment  of  the  thigh  is  constricted  sufficiently 
firm!)-  tf;  intercept  both  the  arterial  and  venous  circulations  com- 
pletely.     Ikfore  the  constrictor  is  tied  the  limb   should  be   held  in 


8o 


PROPHYLACTIC    HEMOSTASIS. 


the  vertical  position  for  a  sufficient  length  of  time  to  render  it 
practically  bloodless.  The  elastic  constrictor  is  either  tied  or,  still 
better,  after  having  secured  the  necessary  degree  of  constriction,  it 
is  held  with  a  pair  of  forceps  at  the  point  of  crossing.  The  pos- 
terior segment  of  the  thigh  is  constricted  by  the  remaining  half  of 
the  tube,  which  is  drawn  sufficiently  tight  behind,  when  the  ends 
of  the  tube  are  made  to  cross  each  other  and  are  brought  forward 
and  made  to  include  the  anterior  segment,  when  they  are  again 
firmly  drawn  and  tied,  or  otherwise  fastened,  above  the  first  con- 
strictor. As  the  anterior  segment  of  the  thigh  contains  the  princi- 
pal blood-vessels,  this  method  of  applying  the  posterior  constrictor 


Fig.  34. — Amputation  completed.     Vessels  readily  accessible  for  ligation. 


furnishes  an  additional  security  against  hemorrhage  from  the  large 
vessels  when  cut  during  the  amputation.  After  the  principal 
blood-vessels  have  been  tied,  the  posterior  constrictor  is  removed 
and  additional  bleeding  points  are  secured  before  the  anterior  con- 
strictor is  removed.  Surface  compression  with  a  compress  wrung 
out  of  a  hot  normal  salt  solution  is  a  valuable  aid  in  minimizing  the 
hemorrhage  after  the  removal  of  the  constrictors.  As  this  method 
of  controlling  hemorrhage  does  not  require  the  presence  of  a  skilled 
assistant,  it  will  prove  of  special  value  in  emergency  cases.  The 
operation  can  be  performed  with  the  instruments  contained  in  every 
pocket-case.      Should  an  elastic  tube  not  be  at  hand,  the  constric- 


ELASTIC    CONSTRICTION. 


8i 


tion  can  be  made  in  a  satisfactory  manner  by  substituting  for  it  a 
cord  made  of  sterile  gauze,  tightened  with  a  lever  of  some  kind,  as 
is  done  in  appl)-ing  the  ordinary  Spanish  windlass. 

Shoulder=joint. — Elastic  constriction  with  the  aid  of  one  or 
two  transfixion  pins  can  be  made  use  of  in  controlling  hemorrhage 
in  disarticulation  at  the  shoulder-joint.  The  transfixion  must  be 
made  on  the  proximal  side  of  the  glenoid  cavity  of  the  scapula. 
A  mattress  or  straight  steel  needle  is  made  to  traverse  the  tissues 
in  an  anteroposterior  direction,  in  such  a  way  that  it  will  pass 
between  the  axillary  vessels  and  the  neck  of  the  scapula.  In  obese 
persons  it  is  well  enough  to  give  an  additional  support  to  the 
elastic  constrictor  by  transfixing  the  skin  on  the  scapular  side  of 
the   acromion    process.      Since   much   tissue   must   be  included  in 


Fig.  35. — .Stump  after  disarticulation  at  the  hip-joint.      Anteroposterior  cutaneous  flaps 
(Clinic,  Rush  Medical  College). 


the  constrictor,  at  least  two  turns  are  necessary  to  insure  the  re- 
quisite degree  of  constriction.  In  amputations  at  the  shoulder- 
joint  elastic  constriction  can,  however,  often  be  dispensed  with  by 
resorting  to  preliminary  ligation  of  the  axillary  artery,  which  can 
readily  be  done  in  the  wound  after  making  the  deltoid  flap.  The 
accomjjanying  vein  should  invariably  be  tied  before  cutting  it  if 
elastic  constriction  is  dispensed  with,  as  a  failure  to  observe  this 
precaution  would  result  in  unnecessary  loss  of  blood  and  might 
possilily  give  rise  to  air  embolism. 

Head. — In  extensive  operations  on  tlie  sktiU  and  in  the  removal 
of  fliffu.se  vascular  tumors  of  the  scalp  elastic  constriction  of  the 
head  renders  great  aid  in  limiting  the  hemorrhage.  A  narrow, 
strong  rubber  band  or  a  piece  of  stout  rubber  tubing  long  enough 
to  encircle  the  head  twice  is  best  adaptetl  for  this  jjurpose.      The 


82 


PROPHYLACTIC    HEMOSTASIS. 


circular  constriction  is  made  on  a  level  with  the  occipital  protuber- 
ance and  at  a  point  in  front  corresponding  with  the  upper  margin 
of  the  eyebrows.  If  the  constrictor  is  properly  applied,  no  trans- 
fixion pins  are  required  (Fig.  36). 

In  the  removal  of  a  limited  racemose  aneurysm  or  circumscribed 
angiomatous  tumors  elastic  constriction  can  be  efficiently  applied  to 
include  the  desired  area  by  the  use  of  transfixion  pins.  At  least 
four  pins  are  required,  and  if  the  territory  is  a  large  one,  more  are 
necessary.  In  operations  on  the  scalp  for  these  indications  each  pin 
is  placed  in  a  locality  where  vessels  of  large  size  lead  to  the  part 
to  be  removed.      All  the  tissues  down  to  the  bone  are  included  in 

the  transfixion,  and 
each  pin  is  made  to 
traverse  an  inch  or 
more  of  the  tissues. 
The  transfixion  must 
be  made  at  a  safe  dis- 
tance from  the  growth 
to  be  removed,  and 
must  include  healthy 
tissue.  With  a  rubber 
band  or  small  rubber 
cord  or  tubing,  elas- 
tic constriction  of  the 
tissue  included  by 
each  pin  is  made  by 
applying  it  in  a  fig- 
ure-of-eight. When 
this  has  been  done, 
circular  constriction 
of  the  field  of  opera- 
tion is  made  by  in- 
cluding all  the  pins 
in  the  constrictor  to 
interrupt  the  circula- 
tion in  all  vessels  lead- 
ing to  and  from  the 
tumor  (Fig.  37).  After  the  removal  of  the  tumor  all  visible  blood- 
vessels are  tied  before  removing  the  common  constrictor.  Later  hem- 
orrhage is  arrested  carefully  after  the  removal  of  each  of  the  pins. 
By  following  this  plan  the  hemorrhage  is  never  profuse,  and  can  be 
arrested  step  by  step  as  the  pins  are  withdrawn.  In  the  absence  of 
pins  of  special  construction  large  safety-pins  answer  an  excellent 
purpose  in  securing  the  benefits  of  elastic  constriction  anywhere 
upon  the  surface  of  the  body. 

Manual  Compression  of  the  Aorta. — For  more  than  fifteen 
years  Macewen  has  resorted  to  manual  compression  of  the  abdomi- 
nal aorta  for  preventing  hemorrhage  during  operations  involving 


Fig.  36. — Elastic  constriction  of  the  skull. 


MANUAL    COMPRESSION    OF    THE    AORTA. 


83 


large  blood-vessels  that  are  under  control  by  this  prophylactic 
hemostatic  resource.  In  disarticulation  at  the  hip-joint,  by  this 
method  of  controlling  hemorrhage  he  never  lost  more  than  two 
ounces  of  blood  from  the  proximal  vessels.  It  has  also  proved  of 
great  service  in  operations  upon  the  pelvic  organs  attended  by  severe 
hemorrhage.  His  method  is  as  follows  :  "  As  the  patient  lies  on 
his  back  on  the  table,  the  assistant,  facing  the  patient's  feet,  stands 
on  the  left  side  of  the  table  on  a  line  with  the  patient's  umbilicus. 
He  then  places  his  closed  right  hand  upon  the  patient's  abdomen,  a 
litde  to  the  left  of  the  middle  line,  the  knuckles  of  the  index-finger 
just  touching  the  upper  border  of  the  umbiHcus,  so  that  the  whole 
closed  hand  will  embrace  about  three  inches  of  the  distal  extremity 
of  the  aorta  above  its  bi- 
furcation (Fig.  38).  The 
assistant  then  standing 
upon  his  left  foot,  his 
right  foot  crossing  his 
left  and  resting  upon  the 
toes  of  the  right, — an 
attitude  commonly  as- 
sumed by  public  speak- 
ers.—  leans  upon  his 
right  hand  and  thereby 
exercises  the  necessary 
amount  of  pressure. 
With  the  index-finger 
of  the  assistant's  left 
hand  the  weight  neces- 
sar\'  for  the  purpose  can 
easily  be  estimated  by 
the  effect  produced  upon 
the  flow  of  blood  through 
the  common  femoral,  at 
the  brim  of  the  pelvis. 
Whenever  the  flow  of 
blood  through  the  fem- 
orals  is  absolutely  ar- 
rested,    the     abdominal 

aorta   is  sufficiently  controlled,  and  no  further  weight  ought  to  be 
applied." 

A  large  experience  has  shown  that  as.sistants  performing  this 
office  can  keep  up  the  compression  for  the  necessary  length  of  time 
witlujiit  undue  fatigue.  If  the  patient  should  cough  or  vomit,  the 
pressure  must  be  increased.  As  in  all  cases  requiring  compression 
of  the  abdominal  aorta  as  a  prophylactic  or  therapeutic  measure, 
the  time  required  is  short.  It  is  reasonable  to  hope  that  this 
method  will  take  the  place  of  instrumental  compression,  as  the 
tnaimal   pressure  can   be   regulated   with   precision   to  the   require- 


Fig.  37.  — Elastic  constriction  of  the  surface  with 
the  aid  of  transfixion  pins,  applicable  in  the  removal 
of  large  vascular  tumors. 


84 


PROPHYLACTIC    HEMOSTASIS. 


merits,  and  consequently  is  less  liable  to  cause  visceral  injuries,  and, 
at  the  same  time,  is  more  reliable  in  controlling  the  hemorrhage. 

Digital  Compression. 
— Digital  compression  is 
a  ready  prophylactic  and 
therapeutic  hemostatic  re- 
source in  controlling  and 
arresting  hemorrhage  any- 
where below  the  axillary 
space  of  the  upper,  and 
below  Poupart's  ligament 
of  the  lower,  extremity. 
With  one  or  more  fingers 
the  principal  blood-vessel 
is  compressed  against  the 
underlying  bone  (Figs.  39 
to  41).  Digital  compres- 
sion is  resorted  to  when 
quick  action  is  required 
and  an  elastic  constrictor 
is  not  at  hand.  The  com- 
pression must  be  continued 
uninterruptedly  until  the 
bleeding  vessel  can  be  tied 
or  pressure  can  be  re- 
placed by  elastic  constric- 
tion or  the  antiseptic  tampon.  The  finger  or  fingers  which  perform 
this  duty  must  not  be  removed  for  a  moment  so  long  as  compres- 
sion is  needed,  and  when  fatigued,  can  be  supported  by  the  fingers 


Fig.  38. — Macewen's  method  for  compression 
of  the  abdominal  aorta  ("American  Text-book  of 

Surgery"). 


Fig.  39. — Digital  compression 
of  the  brachial  artery. 


Fig.  40. — Digital  compression  of  the  brachial  artery. 


of  the  other  hand  rather  than  risk  change  of  hands.  If,  for 
instance,  one  thumb  is  used  to  compress  the  femoral  artery,  the 
disengaged  thumb  can  be  placed  over  it  and  compression  made  con- 


PRELIMINARY    LIGATION    OF   ARTERIES    IN    THEIR    CONTINUITY.       85 


jointly  or  alternately.  Compression  of  the  subclavian  and  iliac 
arteries  by  this  method  is  occasionally  relied  upon,  but  can  not  be 
efficiently  maintained  for  any  considerable  length  of  time. 

Preliminary  Ligation  of  Arteries  in  their  Continuity. — 
The  ligation  of  a  principal  artery  in  its  continuity  for  the  purpose 
of  controlling  hemorrhage  from  its  branches  in  performing  an 
operation  on  the  distal  side  of  the  ligature  is  practised  less  fre- 
quently since  the  rapid  development  of  the  technic  of  hemostasis 
during  the  last  two  decades.  Ligation  of  the  common  carotid 
artery  preliminary  to  removal  of  tumors  in  the  nasopharynx,  the 
pharynx,  and  in  the  parotid  and  submaxillary  regions,  is  seldom 
performed  now,  since  by  the  use  of  hemostatic  forceps  we  are 
better  prepared  to  deal  promptl}^  with  the  hemorrhage  in  the 
wound.  Prophylactic  ligation  of  the  common  carotid  can  not 
always  be  relied  upon  in  guarding 
against  profuse  hemorrhage  in  such 
cases,  more  especially  in  the  removal 
of  tumors  from  the  nasopharynx,  and 
it  is  a  procedure  which  in  itself  is  often 
fraught  with  danger.  In  the  removal 
of  a  nasopharyngeal  tumor  of  large 
size  I  have  resorted  to  preliminary  liga- 
tion of  the  left  common  carotid,  and 
yet  the  patient  died  from  the  imme- 
diate effects  of  the  hemorrhage,  not- 
withstanding the  operation  was  per- 
formed with  the  utmost  speed  and  local 
hemostatics  were  promptly  employed. 
In  persons  advanced  in  years  or  the 
subjects  of  atheromatous  arteries,  pre- 
liminary ligation  of  the  common  carotid 
artery  must  be  resorted  to  with  great 
reserve,  as  it  is  apt  to  result  in  paralysis 

or  even  death.  In  a  case  of  malignant  tumor  of  the  neck  requiring 
partial  excision  of  the  common  carotid  artery  and  the  internal  jugular 
vein  in  its  removal,  the  patient  died  in  less  than  forty-eight  hours 
from  the  immediate  effects  of  the  cerebral  anemia.  In  another  case 
preliminary  ligation  of  the  common  carotid  artery  was  followed  by 
hemiplegia  on  the  opposite  side,  from  which  the  patient  gradually 
recovered  only  at  the  end  of  six  months.  Preliminary  ligation  of 
the  subclavian  artery  is  the  only  hemostatic  resource  in  controlling 
tiie  hemorrhage  during  the  removal  of  the  entire  upper  extremity, 
inclusive  of  scapula  and  clavicle.  Under  such  circumstances  liga- 
tion of  the  subclavian  vessels  is  an  easy  task  after  free  exposure  by 
elevation  of  the  clavicle  after  disarticulation  from  the  sternum.  In 
di.sarticulation  of  the  shoulder-joint  i)rcliminary  ligation  of  the 
axillary  artery  and  vein  can  be  done,  without  any  technical  difficul- 
ties, through  the  wound,  after  making  the  deltoid  or  external  flap. 


Fig. 


41. — Digital  compression  of 
the  femoral  artery. 


86  PROPHYLACTIC    HEMOSTASIS. 

Transperitoneal  ligation  of  the  iliac  arteries  has  recently  received 
much  attention  from  surgeons  in  the  discussion  of  prophylactic 
hemostasis.  Since  Trendelenburg's  position  has  come  into  general 
use  in  difficult  cases  of  pelvic  surgery,  intraperitoneal  ligation  of  the 
iliac  arteries  has  become  a  legitimate  surgical  procedure,  both  as 
a  prophylactic  and  therapeutic  hemostatic  resource.  In  injuries  in 
which  it  becomes  necessary  to  tie  any  of  the  iliac  arteries,  either  for  the 
purpose  of  preventing  or  of  arresting  hemorrhage,  the  intraperitoneal 
operation  is  preferable  to  the  extraperitoneal  route,  with  the  excep- 
tion, perhaps,  of  tying  the  lower  portion  of  the  external  iliac 
artery.  The  extraperitoneal  operation  has  not  always  terminated 
extraperitoneally,  and  many  cases  have  been  recorded,  and  more 
remain  unrecorded,  in  which  the  ligature,  owing  to  the  depth  of 
the  wound  and  the  difficulties  encountered  in  its  application,  has 
included  important  structures,  such  as  the  ureter  and  accompanying 
iliac  vein.  Such  mishaps  are  responsible  for  many  of  the  failures. 
Transperitoneal  ligation  of  the  iliac  arteries  has  been  a  subject  of 
careful  investigation  by  Dennis  and  S.  K.  Morton.  The  latter 
author  has  recently  given  the  statistics  of  29  operations.  Of  the 
29  cases,  22  recovered  and  7  died.  Of  the  fatal  cases,  not  one 
was  due  to  abdominal  complication.  In  5  cases  the  common  iliac 
was  ligated,  and  of  these  i  died,  death  being  caused  by  gangrene. 
Of  the  9  cases  of  ligation  of  the  internal  iliac,  2  died.  The  exter- 
nal iliac  was  tied  i  5  times,  with  4  deaths.  Lange  tied  the  common 
iliac  by  the  intra-abdominal  route  the  first  time  in  1883.  The 
internal  iliac  was  ligated  by  Leroy  McLean  in  1872,  and  M.  Rich- 
ardson tied  the  external  iliac  in  1886. 

Trendelenburg's  position  is  essential  in  performing  this  opera- 
tion, as  it  obviates  extensive  evisceration  in  finding  and  securing 
the  vessel  in  any  part  of  its  course.  The  abdomen  should  be 
opened  by  making  McBurney's  muscle-splitting  incision.  For  the 
common  and  internal  iliac  the  median  incision  is  preferable.  The 
parietal  peritoneum  is  incised  over  the  vessel  where  the  ligature  is 
to  be  applied,  and,  after  tying  the  ligature,  the  peritoneal  incision 
is  closed  with  a  few  catgut  sutures.  In  urgent  cases,  however, 
this  part  of  the  operation  can  be  omitted,  with  a  view  to  saving 
time,  without  any  detrimental  results. 

Temporary  Ligation  of  Arteries. — The  temporary  ligation 
will,  in  all  probability,  take  the  place,  in  the  near  future,  of  prelimin- 
ary ligation.  The  exclusion  of  blood  from  a  limited  segment  of  an 
artery  for  a  short  time  is  not  incompatible  with  the  patency  of  the 
lumen  of  the  vessel  at  the  point  of  temporary  constriction,  pro- 
vided the  intima  is  not  injured.  My  experiments  on  animals  have 
demonstrated  that  a  double  ligature  placed  half  an  inch  apart  can 
remain  for  twenty-four  hours  without  interfering  with  the  subse- 
quent complete  restoration  of  function  of  the  temporarily  excluded 
part  of  the  artery.  Only  one  of  the  many  experiments  with  this 
special  point  in  view  will  be  quoted  : 


TEMPORARY    LIGATION    OF    ARTERIES.  8/ 

''Experiment  2j. — Left  femoral  artery  of  goat.  Double  liga- 
ture of  coarse  catgut.  Removal  of  ligatures  twenty-four  hours 
after  operation.  Animal  killed  nine  days  after  ligation.  On  re- 
moval of  the  ligatures  circulation  not  interrupted.  Ligated  por- 
tions of  vessel  considerably  smaller.  Lumen  not  obliterated. 
Inner  walls  of  vessel  at  the  seat  of  operation  studded  with 
minute  patches  of  exudation  material,  the  product  of  recent  end- 
arteritis." 

In  operations  on  the  pharynx,  parotid,  and  submaxillary  regions 
for  the  removal  of  large  tumors  in  cases  in  which  profuse  hemor- 
rhage is  expected,  it  has  been  my  practice  for  many  years  to 
expose  the  carotid  artery  on  a  level  with  the  upper  border  of  the 
thyroid  cartilage,  and  to  surround  the  common  carotid  with  a  catgut 
ligature,  which  is  to  be  used  as  a  temporary  or  permanent  ligature, 
as  the  results  of  the  operation  might  indicate.  Such  provision 
against  hemorrhage  is  a  great  comfort  to  the  surgeon,  and  in  the 
event  of  sudden  profuse  hemorrhage,  constitutes  a  prompt  and  effi- 
cient aid  in  controlling  or  arresting  it.  The  use  of  the  temporary 
ligature  as  a  proph\dactic  hemostatic  has  recently  received  much 
favor  in  the  practice  of  Schonborn,  Senger,  and  Riese.  There  can 
be  little  doubt  but  that  it  will  be  made  use  of  in  abdominal  and 
pelvic  operations,  and  in  disarticulation  at  the  hip-joint  as  a  substi- 
tute, in  appropriate  cases,  for  the  permanent  ligation  of  the  com- 
mon iliac  artery  and  its  branches. 

Percutaneous  Temporary  Ligation  of  Arteries  and  Veins. — 
The  prevention  of  hemorrhage  by  percutaneous  ligation  of  arteries 
and  veins  is  not  a  common  practice,  but  is  applicable  in  exceptional 
cases.  Percutaneous  ligation  of  the  common  femoral  artery  has 
been  proposed  as  a  proper  precaution  for  preventing  hemorrhage 
during  disarticulation  at  the  hip-joint.  It  would  be  difficult  to 
prove  the  superiority  of  such  a  procedure  over  digital  compression 
of  the  femoral  artery.  This  prophylactic  hemostatic  measure  may 
prove  to  be  of  value  in  the  removal  of  vascular  tumors  by  cutting 
off  the  blood  supply  to  the  part  to  be  removed  duiing  the  opera- 
tion. Nicaise  made  use  of  percutaneous  ligation  of  veins  for  pre- 
venting profuse  hemorrhage  during  the  removal  of  very  vascular 
malignant  tumors  of  the  mammary  gland,  and  found  that  it  proved 
u.seful  in  lessening  the  amount  of  hemorrhage.  Percutaneous  liga- 
tion of  arteries  and  veins  will  always  prove  useful  in  the  removal 
of  vascular  growths  when  elastic  constriction  can  not  be  applied. 
The  percutaneous  ligature  should  be  permitted  to  remain  ///  situ 
until  the  ligated  vessel  has  become  permanently  obliterated — that 
is,  from  two  to  seven  days,  according  to  the  anatomic  character  and 
.si/.e  of  the  ligated  ve.s.sel.  In  most  of  these  ca.ses  it  is  advi.sable  to 
interpo.se  a  small  compress  of  aseptic  gauze  between  the  ligature 
and  the  surface  of  the  body,  which  will  not  interfere  with  the  con- 
striction of  the  ve.s.sel  and  at  the  same  time  protect  the  skin  again.st 
the  harmful  effects  of  linear  ])rcssure. 


88  PROPHYLACTIC    HEMOSTASIS. 

Galvanocautery  and  Thermocautery.  —  The  galvanocaustic 
loop,  so  strongly  advocated  years  ago  by  Middeldorpf  as  a  pro- 
phylactic against  hemorrhage  in  the  removal  of  vascular  growths, 
has  become  an  almost  obsolete  surgical  procedure  since  the  intro- 
duction of  the  different  kinds  of  hemostatic  forceps  and  other  efficient 
local  means  of  guarding  against  hemorrhage.  No  modern  surgeon 
has  any  use  for  the  galvanocautery  in  the  prevention  of  hemorrhage. 


Fig.  42. — Vasotribe  of  Doyen. 


During  the  time  the  galvanocaustic  wire  was  a  popular  resource  in 
preventing  hemorrhage  during  the  performance  of  operations  upon 
very  vascular  tissues  many  surgeons  were  disappointed  in  its  use 
for  this  purpose.  While  the  red-hot  wire  in  cutting  its  way  through 
the  tissues  was  found  reliable  in  preventing  hemorrhage  from  capil- 
laries and  small  venous  and  arterial  vessels,  it  did  not  prove  suc- 
cessful in  rendering  bloodless  operations  in  which  vessels  of  any 
considerable  size  had  to  be  divided.     The  Paquelin  cautery  retains 


>    /. 


jAr  A^, 


Fig.  43. — Angiotribe  of  Tuffier. 


its  reputation  in  the  removal  of  tumors  from  very  vascular  organs, 
such  as  the  liver,  spleen,  and  kidney,  or  in  making  incision  into  the 
same  for  various  pathologic  indications.  When  used  for  such  pur- 
pose, the  knife-point  of  the  instrument  should  be  heated  to  a  dull 
red  heat  only,  as  a  white  heat  largely  detracts  from  its  hemostatic 
effects. 

Angiotripsy. — The   most  modern  prophylactic  hemostatic  re- 
source is  angiotripsy,  as  devised  and  practised  by  Tuffier  and  Doyen. 


ANGIOTRIPSY. 


89 


The  principle  is  an  old  one,  represented  by  the  ecraseur,  but  its 
application  in  the  modern  form  is  new.  It  consists  in  the  use  of 
strong  forceps  which  crush  the  tissues  and  vessels  that  come  into 
the  grasp  of  its  jaws,  thus  creating 
conditions  which  prevent  bleeding 
and  render  the  use  of  ligatures 
superfluous.  This  method  of  con- 
trolling hemorrhage  has  given  ex- 
cellent satisfaction  in  performing 
vaginal  hysterectomy,  and  will 
undoubtedh'  be  applied  to  some 
other  regions  of  the  body  as  a 
substitute  for  elastic  constriction 
and  other  local  means  of  guarding 
against  unnecessary  loss  of  blood. 
This  procedure  presents  many  ad- 
vantages over  other  local  hemo- 
static prophylactic  measures  in  all 
instances  where  the  field  of  opera- 
tion is  limited  to  vessels  of  small 
size,  and  where  the  crushed  tissues 
are  not  exposed  to  any  risk  of 
infection. 

Spanish  Windlass. — This  is  a  good  substitute  for  the  preven- 
tion as  well  as  the  arrest  of  hemorrhage  in  emergency  and  military 
surgery  when  no  elastic  constrictor  is  at  hand  (Fig.  44).  A  hand- 
kerchief is  tied  loosely  around  the  limb  at  the  point  where  constric- 
tion is  needed,  and  is  tightened  by  passing  a  stick,  a  hemostatic 
forceps,  or  a  bayonet  underneath  it,  and  tightening  it  to  the  re- 
quisite extent  by  twisting.  The  effect  of  the  circular  compression 
is  increased  by  placing  a  pad  over  the  artery. 

Ecraseur. — As  a  prophylactic  hemostatic  the  ecraseur  is  men- 
tioned to  complete  the  account  of  the  prevention  of  hemorrhage. 
Chassaignac  carried  the  use  of  this  instrument  so  far  that  he 
resorted  to  it  in  some  cases  as  a  substitute  for  the  knife  in  ampu- 
tations.     It  is  seldom,  if  ever,  employed  at  the  present  time. 


Fig.  44. 


-Spanish  windlass. 


CHAPTER  V. 

TREATMENT  OF  HEMORRHAGE* 

Skilful  treatment  of  hemorrhage  is  an  infalHble  criterion  of 
good  surgery.  The  aptitude  of  a  surgeon  for  his  profession  can 
readily  be  estimated  by  the  prompt  selection  and  the  proper  appli- 
cation of  the  different  hemostatic  resources  in  the  treatment  of 
unexpected  alarming  hemorrhage.  Dieffenbach  has  well  said : 
"  From  the  behavior  of  a  surgeon  in  cases  of  severe  hemorrhage 
are  we  able  to  judge  of  what  metal  he  is  made."  Profuse  hemor- 
rhage alarms  the  professional  as  well  as  the  layman.  The  sight 
of  blood  pleases  only  the  pervert ;  it  is  as  distressing  to  the  sur- 
geon as  it  is  to  the  spectator.  Goethe  says  that  "blood  is  a  very 
peculiar  juice,"  and  every  surgeon  is  more  than  willing  to  subscribe 
to  this  poetic  and  realistic  definition  of  the  life-giving  fluid,  with 
which  he  becomes  so  familiar  from  day  to  day  during  his  walk  of  life. 
The  mechanical  measures  employed  in  the  management  of  hemor- 
rhage have  at  all  times  constituted  subjects  of  special  interest  to 
the  surgeon,  whose  function  it  is  to  treat  all  kinds  of  accidents, 
and  invade  the  body  in  search  for,  and  to  remove  or  correct, 
affections  within  the  reach  of  curative  or  palliative  surgical  treat- 
ment. Presence  of  mind,  a  steady  hand,  prompt  action,  an 
accurate  knowledge  of  anatomy,  familiarity  with  the  various  hemo- 
static agents,  and  clear  ideas  on  the  process  of  obliteration  of 
blood-vessels  are  prerequisite  conditions  for  success  in  the  treat- 
ment of  the  most  frequent  and,  at  the  same  time,  the  most  alarm- 
ing emergency  which  presents  itself  to  the  surgeon — hemorrhage. 
Ignorance,  hesitation,  and  timidity  in  the  event  of  sudden,  un- 
expected, and  alarming  hemorrhage  only  too  often  mean  death  ; 
while,  on  the  other  hand,  the  exercise  of  skill  founded  on  knowl- 
edge is  often  the  means  of  saving  human  life  under  the  most  des- 
perate circumstances.  To  the  benefit  of  suffering  humanity,  fear 
of  hemorrhage  has  deterred  pretenders  from  performing  bloody 
operations,  which  has  left  the  cultivation  of  the  field  of  operative 
surgery  to  men  of  skill  and  science.  Perhaps  no  branch  of  sur- 
gery has  reached  a  higher  degree  of  perfection  than  the  treatment 
of  injuries  and  diseases  of  blood-vessels.  The  bold  operations 
that  have  characterized  the  present  era  of  surgery  owe  their  incep- 
tion and  their  legitimacy  largely  to  the  added  resources  and  im- 
proved methods  of  preventing  and  arresting  hemorrhage. 

The  surgeon  who  is  perfectly  familiar  with  the  modern  prophyl- 
actic and  therapeutic  hemostatic  resources,  and  who  has  the  apti- 
tude and  necessary  dexterity  to  apply  them  promptly  and  properly 

90 


CLASSIFICATION    OF    HEMORRHAGE.  9 1 

when  needed,  is  the  one  best  prepared  for  efficient  emergency 
work.  A  thorough  knowledge  of  the  technic  of  modern  hemo- 
stasis,  a  quick  selection  of  the  appropriate  agent  for  each  individual 
case,  and  promptness  of  action  characterize  the  modern  operator 
and  the  successful  general  practitioner  in  the  management  of  emer- 
gency cases.  The  fear  of  blood,  from  which  no  surgeon  or  practi- 
tioner is  entirely  free,  can  be  overcome,  in  part  at  least,  by  the 
consciousness  of  being  able  to  grasp  the  situation  quickly  and 
being  in  possession  of  the  various  hemostatic  resources  and  the 
necessary  knowledge  to  apph'  them  promptly  and  intelligently. 

Classification  of  Hemorrhage. — For  scientific  and  practical 
reasons,  hemorrhage  has  been  classified  according  to  its  source 
into:  (i)  Arterial;   (2)  venous  ;   (3)  capillary. 

I.  The  hemorrhage  is  arterial  if  the  left  side  of  the  heart  or  any 
of  the  arteries  is  injured  or  cut.  The  blood  is  of  a  bright  red  color, 
and  escapes  from  the  wound  in  jets — that  is,  the  stream  is  not  con- 
tinuous. The  jets  are  synchronous  with  the  heart's  action  and  the 
arterial  wave.  The  size  of  the  stream  corresponds  with  the  lumen 
of  the  divided  arter}'  or  the  size  of  the  heart  or  vessel  wound. 
Clean-cut  wounds  give  rise  to  profuse  bleeding,  while  contused  and 
lacerated  wounds,  even  if  the  injured  vessel  is  of  considerable  size, 
are  known  to  antagonize  hemorrhage,  as  the  crushed  or  lacerated 
tissues  diminish  or  prevent  mechanically  the  escape  of  blood  and, 
by  the  formation  of  a  thrombus,  furnish  the  best  possible  conditions 
for  spontaneous  arrest  of  hemorrhage.  A  limb  may  be  torn  from 
the  body  by  a  cannon-ball  or  crushed  by  a  railway  train  without 
any  considerable  loss  of  blood.  A  limb  may  be  disarticulated  at 
any  of  its  joints  by  a  traction  injury,  such  as  a  machinery  accident, 
without  causing  any  serious  loss  of  blood.  If  an  artery  is  put  on 
the  stretch,  the  intima  gives  way  first,  and  the  cuff  thus  formed  by 
the  retraction  of  the  torn  intima  at  once  narrows  the  lumen  of  the 
vessels.  If  the  force  is  continued  and  the  remaining  tunics  are  sev- 
ered, the  shreds  formed  from  the  outer  two  coats  do  their  share  in 
mechanically  preventing  the  escape  of  blood  and  in  determining  the 
speedy  formation  of  a  thrombus.  Needle  puncture  of  the  ventricles 
and  any  of  the  large  arteries  is  not  attended  by  any  danger  of  hem- 
orrhage, as  the  small  tunnel  formed  on  withdrawing  the  needle  is 
at  once  made  impervious  by  the  displaced  muscle  and  connective- 
ti.ssue  fibers  resuming  their  former  relations.  Stab  wounds  made 
with  a  narrow  blade  occasionally  heal  without  surgical  intervention 
and  without  the  subsequent  development  of  an  aneurxsm,  by  the 
formation  of  a  minute  white  mural  thrombus  sealing  the  intima 
wound,  and  by  healing  of  the  balance  of  the  visceral  wound  by  ti.ssue 
proliferation  from  the  connective  tissue.  Recent  experiments  and 
experience  in  mihtary  surgery  have  demonstrated  beyond  all  possible 
doubt  that  the  small-caliber  jacketed  bullet  inflicts  wounds  more 
closely  allied  to  incised  than  to  contused  wounds,  and  consequently, 
when  the  wound  involves  blood-ves.sels  of  any  magnitude,  the  risk 


Q2  TREATMENT    OF    HEMORRHAGE. 

of  hemorrhage  is  greater  than  from  similar  Avounds  made  by  the 
large-cahber  leaden  bullet. 

2.  Venous  hemorrhage  is  recognized  by  the  dark  color  of  the 
blood  and  the  continuous  stream  as  the  blood  escapes  from  the  in- 
jured vessel.  The  blood  stream  is  sometimes  incompletely  inter- 
rupted in  wounds  of  the  large  veins  at  the  base  of  the  neck  and  the 
axillary  spaces,  locations  in  which  the  respiratory  movements  influ- 
ence the  force  of  the  venous  current.  The  same  is  true  of  wounds  of 
any  of  the  large  intracranial  sinuses.  The  stream  is  diminished  or 
partly  interrupted  during  inspiration,  and  reaches  its  maximum 
volume  and  velocity  at  the  end  of  the  expiratory  movements  and 
during  coughing  and  vomiting,  acts  which  always  increase  intra- 
venous pressure.  The  flow  of  blood  from  a  vein  wound  is  also  in- 
fluenced by  arterial  pulsations  if  the  injured  vessels  lie  upon  or  are  in 
close  contact  with  an  artery  of  considerable  size.  In  such  instances 
the  stream  is  continuous,  but  varies  somewhat  in  intensity  with 
the  arterial  pulsations.  Position  has  a  potent  influence  on  venous 
hemorrhage  :  the  dependent  position  favors  it ;  elevation  frequently 
controls  it  completely.  The  influence  of  the  force  of  gravitation 
on  venous  hemorrhage  is  seen  in  the  most  striking  and  convincing 
manner  in  wounds  of  the  superior  longitudinal  sinus. 

For' the  purpose  of  ascertaining  the  conditions  which  induce 
air  embolism  and  which  aggravate  or  diminish  hemorrhage  in 
wounds  of  the  superior  longitudinal  sinus,  I  made  a  series  of 
experiments  a  number  of  years  ago  on  dogs  and  horses.  A  de- 
tailed account  of  only  one  of  these  experiments  will  be  given 
here,  as  it  furnished  conclusive  evidence  as  to  the  influence  of  the 
position  of  the  head  in  determining  either  air  embolism  or  hemor- 
rhage. 

"  Experiment  ^. — Horse,  fourteen  years  old,  in  good  condition. 
This  experiment  was  made  for  the  special  purpose  of  confirming 
the  suspicions  already  gained  that  the  force  of  gravitation  consti- 
tutes the  most  important  factor  in  determining  the  admission  of  air 
into  an  open  sinus  of  the  dura  mater  ;  consequently  no  anesthetic 
was  used,  but  the  animal  was  securely  held  by  a  bit,  and  the  opera- 
tion was  performed  without  any  difficulty  while  the  animal  was  in  a 
standing  position,  with  the  head  elevated.  With  the  trephine  and 
chisel  an  oval  opening  about  two  and  a  half  inches  in  extent  was 
made  over  the  longitudinal  sinus.  After  all  oozing  had  ceased, 
the  sinus  being  fully  in  view,  its  anterior  wall  was  incised  trans- 
versely. The  edges  of  the  wound  immediately  retracted,  forming 
a  diamond-shaped  opening  through  which  blood  escaped  in  moder- 
ate force,  but  not  nearly  so  copiously  as  on  previous  occasions 
when  the  animals  were  in  the  prone  position. 

"  During  the  first  inspiration  after  the  sinus  was  opened  air 
entered  with  a  loud  gurgling  or  lapping  sound,  and  in  applying  the 
ear  over  the  apex  of  the  heart  a  loud,  churning  sound  was  heard, 
synchronous  with  the  movements  of  the  organ.     During  expiration 


CAPILLARY    HEMORRHAGE.  93 

air-bubbles  were  seen  to  escape  from  the  proximal  end  of  the  sinus. 
As  soon  as  the  head  was  lowered  the  hemorrhage  became  very 
profuse,  but  air  never  entered  as  long  as  the  animal's  head  was 
held  in  this  position.  As  soon  as  the  head  was  elevated,  however, 
hemorrhage  either  ceased  entirely  or  was,  at  least,  greatly  dimin- 
ished, but  air  was  sure  to  enter  during  inspiration.  These  mancEU- 
vers  were  repeated  a  number  of  times,  and  always  with  the  same 
results.  As  the  amount  of  air  that  was  aspirated  increased  the 
respirations  became  more  labored,  and  indications  of  cyanosis 
became  apparent.  An  attempt  was  now  made  to  close  the  sinus 
wound  by  sutures,  and  in  this  wa\'  arrest  the  hemorrhage.  Three 
catgut  sutures  were  passed  through  both  edges  of  the  wound,  but 
on  attempting  to  approximate  its  margins  every  one  of  them  tore 
through  the  tissues  before  the  edges  were  in  apposition,  proving 
conclusiveh'  that  transverse  wounds  of  the  longitudinal  sinus  can 
not  be  closed  by  suturing,  owing  to  the  unyielding  nature  of  the 
tissues.  The  external  wound  was  completely  closed  b\'  the  con- 
tinuous suture,  and  a  firm,  graduated,  antiseptic  compress  applied 
over  it  controlled  the  bleeding.  The  wound  healed  by  primary 
intention.  The  defect  in  the  skull  remained  permanent.  The 
animal  was  killed  four  weeks  later.  The  trephine  opening  was  filled 
in  with  cicatricial  tissue.  The  proximal  end  of  the  sinus,  just  behind 
the  trephine  opening,  contained  one  large  granulation  thrombus. 
Cicatricial  tissue  filled  almost  the  entire  lumen  of  the  sinus. 
Anteriorly  the  sinus  was  somewhat  contracted  and  smooth  ;  no 
thrombus  or  evidences  of  tissue  proliferation  were  found  here.  The 
circulation  was  apparently  restored  by  the  formation  of  a  new 
channel  or  dilatation  of  a  preexisting  one  ;  this  new  sinus  was 
located  to  the  left  of  the  median  line.  The  lateral  sinuses  were 
very  much  enlarged.  Hemorrhage  from  any  of  the  large  veins  of 
the  extremities  will  cease  spontaneously  by  placing  the  limb  in  a 
vertical  position,  while  when  the  limb  is  placed  in  a  hanging  posi- 
tion it  may  endanger  life." 

3.  The  so-called  surface,  or  parenchymatous,  oozing  is  largely 
of  capillary  origin,  but  not  entirely  so,  as  many  of  the  smallest 
veins  and  arteries,  the  bleeding  points  of  which  can  not  be  seen, 
furnish  an  important  source  of  this  form  of  hemorrhage.  The  blood 
is  therefore  partly  venous  and  partly  of  arterial  origin.  The  oozing 
while  in  progress  is  continuous  and  usually  distributed  diffusely 
over  the  surface  of  the  wound,  but  is  most  troublesome  where  the 
capillary  ves.sels  are  numerous.  In  amputations  parenchymatous 
hemorrhage  from  the  medullary  tissue  is  frequently  encountered, 
owing  to  the  delicate  structure  of  the  walls  of  the  small  blood- 
vessels, the  absence  of  muscular  tissue,  and  the  limited  amount  of 
firm  connective  tissue.  Capillary  hemorrhage  is  to  be  feared  in 
wounds  of  soft  vascular  organs,  such  as  the  liver,  spleen,  and  kid- 
neys. It  is  mo.st  profuse  in  hemophilic  subjects  and  in  patients 
suffering  from  .sepsis  or  organic  disea.se  of  organs  which  impedes 


94  TREATMENT    OF    HEMORRHAGE. 

the  circulation,  such  as  valvular  disease  of  the  heart,  pulmonary 
emphysema,  cirrhosis  of  the  liver,  varicosity  of  the  veins,  etc.  In 
a  case  of  very  profuse  and  obstinate  capillary  hemorrhage  follow- 
ing amputation  of  the  leg  that  came  under  my  observation,  subse- 
quent microscopic  examination  of  the  muscle  tissue  revealed  ex- 
tensive degenerative  changes  incident  to  the  presence  of  encysted 
trichinae  as  the  cause  of  the  troublesome  parenchymatous  oozing. 
Under  ordinary  circumstances  capillary  hemorrhage  is  arrested 
spontaneously  by  the  formation  of  a  minute  thrombus  in  the  cut 
end  of  the  vessels.  Thrombus  formation  is  effected  most  speedily 
and  effectively  in  cases  in  which  the  coagulability  of  the  blood  is 
not  impaired,  and  when  the  tissues  of  the  wound  and  the  structure 
of  the  vessels  are  favorable  to  retraction  of  the  cut  ends  from  the 
surface. 

Spontaneous  Arrest  of  Hemorrhage. — Nature's  resources  in 
effecting  spontaneous  arrest  of  hemorrhage  consist  in  the  formation 
of  a  coagulum  which  mechanically  blocks  the  wound  and  the 
diminution  of  intravascular  pressure,  both  conditions  which  favor 
thrombus  formation.  Cessation  of  hemorrhage  without  surgical 
intervention  depends  largely  on  the  caliber  of  the  vessel  injured, 
the  structure  of  the  vessel-wall,  the  degree  of  intravascular  pressure, 
and  the  size  and  nature  of  the  vessel  wound.  Complete  transverse 
wounds  of  a  large  vessel,  such  as  the  common  carotid  artery  or  the 
internal  jugular  vein,  made  with  a  sharp  instrument,  bleed  most 
freely  and  present  the  most  unfavorable  conditions  for  spontaneous 
hemostasis.  Incised  lateral  wounds  of  the  large  vessels  not  only 
bleed  more  freely  than  lacerated  wounds  of  the  same  size,  but  also 
present  more  unfavorable  conditions  for  effective  spontaneous  hemo- 
stasis by  thrombosis.  Perhaps  the  most  unfavorable  conditions  for 
thrombus  formation  are  to  be  found  in  pathologic  vessel  defects  as 
they  occur  in  ulcer  of  the  stomach,  typhoid  ulcers,  and  occasionally 
in  tubercular  abscesses  the  seat  of  secondary  mixed  infection  with 
pus-microbes.  The  degree  of  intravascular  pressure  has  a  most 
important  bearing  on  spontaneous  arrest  of  hemorrhage.  It  may 
be  stated  as  a  rule,  to  which  there  are  few,  if  any,  exceptions,  that 
the  greater  the  intravascular  pressure,  the  gi eater  are  the  difficulties 
to  be  overcome  in  the  arrest  of  the  bleeding  by  thrombus  formation. 
Cohnheim  says  :  "  When  a  defect  or  gap  is  produced  at  any  point 
in  the  vascular  system,  all  resistance  ceases  there,  and  the  blood 
will,  in  consequence,  flow  toward  it  and  escape  through  the  aperture 
with  an  energy  which  naturally  is  greater  the  higher  the  pressure 
prevailing  in  the  part  of  the  vascular  system  involved.  A  thrombus, 
once  established,  obstructs  the  lumen  of  the  blood-vessel  injured 
just  so  long  as  its  adhesion  to  the  orifice  of  the  wound  is  sufficient 
to  resist  the  intravascular  pressure." 

It  is  for  these  reasons  mainly  that  hemorrhage  from  vein 
wounds  is  arrested  spontaneously  more  frequently  and  promptly 
than  arterial  hemorrhage.      In  profuse  hemorrhage,  particularly  if 


SYMPTOMS    AND    DIAGNOSIS.  95 

a  large  bIood-\essel  is  the  principal  source,  no  attempt  at  spontane- 
ous arrest  of  hemorrhage  takes  place  until,  by  the  loss  of  blood,  the 
force  of  the  heart's  action  is  sufficiently  reduced  to  diminish  intra- 
vascular tension  to  a  degree  compatible  with  thrombus  formation. 
It  is  on  this  account  that  the  administration  of  stimulants  is  abso- 
lutely contraindicated  in  the  treatment  of  hemorrhage  until  the 
bleeding  has  been  arrested  by  ligation  or  otherwise,  or  b)-  the  for- 
mation of  a  thrombus  sufficiently  firm  and  adherent  to  resist 
effectuall}'  the  increasing  intravascular  pressure  following  the  use 
of  stimulants.  It  would  appear  justifiable,  in  cases  of  internal  in- 
accessible hemorrhage,  to  resort  to  abstraction  of  blood  for  the 
purpose  of  reducing  intravascular  pressure  as  low  as  is  compatible 
with  the  circulation,  for  the  purpose  of  aiding  spontaneous  arrest 
of  hemorrhage  by  thrombosis.  Such  therapeutic  intervention  in 
the  treatment  of  apoplexy,  for  instance,  to  prov^e  beneficial  must 
be  had  recourse  to  immediately  or  soon  after  the  hemorrhage  has 
commenced.  It  would  probably  be  worse  than  useless  after  a 
sufficient  quantity  of  blood  has  escaped  to  produce  complete  hemi- 
plegia and  coma.  Thrombus  formation,  upon  which  everything 
depends  in  the  spontaneous  arrest  of  hemorrhage,  takes  place 
promptly  when  the  normal  coagulability  of  the  blood  has  not  been 
impaired,  and  when  the  vessel  wound  is  torn  and  ragged,  as  is  the 
case  in  lacerated  and  crushed  wounds,  and  when  intravascular  pres- 
sure is  at  a  minimum  either  as  a  normal  condition  in  vein  wounds 
or  when  it  has  been  rendered  so  in  arteries  by  the  effects  of  the 
injury  or  loss  of  blood.  When  blood  leaves  the  current  and  comes 
in  contact  with  cut,  crushed,  or  lacerated  tissues,  the  intrinsic  ten- 
dency to  coagulation  manifests  itself,  and  under  favorable  circum- 
stances a  thrombus  forms  and  hemorrhage  ceases.  During  re- 
action from  the  depression  incident  to  the  loss  of  blood,  a  soft, 
recent  thrombus  is  often  washed  away  and  hemorrhage  recurs  and 
continues  until  the  intravascular  pressure  is  again  sufficiently  re- 
duced for  thrombus  formation  to  occur.  It  is  in  such  cases  of  relaps- 
ing internal  hemorrhage  that  surgeons  are  occasionally  led  astray 
in  making  a  correct  diagnosis,  mistaking  hemorrhage  for  shock. 
In  permanent  arrest  of  hemorrhage  by  thrombus  formation  the 
lumen  of  the  vessel,  temporarily  blocked  by  the  adherent  thrombus, 
ultimately  becomes  obliterated  in  the  same  manner  and  by  the 
same  process  as  after  ligation.  The  thrombus  serves  the  purpo.se 
of  a  temporary  framework  for  the  granulations  which  spring  from 
the  intima  and  the  connective  tissue,  and  is  ultimately  removed  and 
the  lumen  of  the  ves.sel  permanently  obliterated  by  the  resulting 
intravascular  scar. 

Symptoms  and  Diagnosis. — The  symptoms  and  diagnosis  in 
external  licniorrhage  arc  easily  understood.  A  careful  analysis  of 
the  symptoms  is  often  required  to  differentiate  correctly  between 
internal  hemorrhage  and  shock,  as  these  two  conditions  arc  a.ssoci- 
ated    with    injuries   and   operations   and   frequently  resemble   each 


^6  TREATMENT    OF    HEMORRHAGE. 

Other  very  closely.  Time  is  an  important  element  in  determining 
the  gravity  of  the  symptoms  in  hemorrhage.  The  loss  of  blood 
under  high  pressure  from  a  large  vessel  near  the  brain  or  heart  is 
followed  by  alarming  symptoms  almost  from  the  commencement 
of  the  hemorrhage.  The  loss  of  a  pint  of  blood  in  two  or  three 
minutes  produces  a  much  more  profound  impression  than  the  loss 
of  three  times  that  amount  by  gradual  oozing.  The  constitutional 
symptoms  make  their  appearance  quickly  and  in  a  marked  manner 
in  profuse  hemorrhage  from  the  large  intracranial  vessels,  the 
sinuses,  and  the  middle  meningeal  artery.  The  acute  cerebral 
anemia  thus  produced  is  characterized  by  a  deadly  pallor  of  the 
face,  cold  extremities,  dilated  pupils,  loss  or  huskiness  of  voice, 
rapid,  small,  quivering  pulse,  shallow,  rapid  respiration,  frequently 
interrupted  by  yawns  or  deep  sighs,  rushing,  roaring  noise  in  the 
ears,  failing  eyesight,  nausea,  and  restlessness.  These  are  the 
symptoms  that  distinguish  acute  anemia  from  hemorrhage,  and  if 
death  follows,  it  is  often  preceded  by  slight  convulsions.  If  the 
loss  of  blood  is  more  gradual,  the  pupils  become  widely  dilated, 
the  eyes  staring,  the  face  and  lips  assume  a  wax-like  appearance, 
the  pulse  is  small  and  fluttering,  breathing  is  rapid  and  irregular, 
the  surface  is  cold,  and  the  forehead  is  bathed  in  a  clammy  per- 
spiration. In  gradual  hemorrhage  these  symptoms  increase  in 
gravity  with  the  amount  of  blood  lost ;  in  other  words,  the  symp- 
toms are  progressive,  a  circumstance  which  it  is  important  to 
remember  in  distinguishing  between  hemorrhage  and  shock,  as  in 
the  latter  condition  the  maximum  symptoms  appear  at  once.  In 
shock  consciousness  is  retained,  although  it  may  be  somewhat 
impaired.  In  grave  cases  of  hemorrhage  the  patient  falls  into 
syncope  and  remains  unconscious  until  reaction  sets  in.  Vomiting 
and  distressing  thirst  are  prominent  symptoms  in  acute  anemia 
from  gradual  hemorrhage.  In  cases  of  hemorrhage  into  any  of 
the  three  large  cavities  of  the  body  the  conclusions  drawn  from  the 
general  symptoms  must  be  verified  by  a  careful  study  of  the  local 
symptoms.  In  intracranial  hemorrhage  the  loss  of  blood  is  slight, 
and  the  diagnosis  must  be  based  on  the  focal  symptoms,  which  in 
apoplexy  and  hemorrhage  from  the  middle  meningeal  artery  and 
its  branches  enable  us  not  only  to  recognize  the  existence  of  the 
accident,  but  we  are  also  able  to  locate  the  extravasation.  In 
hemorrhage  into  the  pericardium  the  heart-sounds  are  distant,  and 
percussion  reveals  the  typical  increased  pericardial  dullness.  Hemo- 
thorax is  recognized  by  the  usual  signs  that  indicate  the  existence 
of  fluid  in  the  free  pleural  cavity  and  by  displacement  of  the  heart. 
The  accumulation  of  any  considerable  quantity  of  blood  in  the 
peritoneal  cavity  gives  rise  to  physical  signs  that  can  not  easily  be 
mistaken,  more  especially  if  the  patient  is  placed  in  different  posi- 
tions in  recumbency. 

Treatment  of  Hemorrhage. — A  full  mastery  of  the  technic  of 
modern  hemostasis  is  an  essential  prerequisite  to  successful  surgery. 


ASEPTIC    LIGATURE.  97 

Careful  hemostasis  is  not  only  necessary  to  guard  against  loss  of 
blood,  but  it  is  likewise  indicated  to  place  the  injured  part  in  the 
best  possible  condition  for  an  ideal  healing  of  the  wound.  The 
presence  of  blood  in  a  wound  not  only  interferes  with  a  speedy  and 
satisfactory  healing,  but  furnishes,  at  the  same  time,  two  pre- 
disposing conditions  for  infection — tension  and  a  culture-medium 
for  the  growth  of  pathogenic  microbes.  Extravasated  blood  is 
always  a  dead  substance,  and  should  be  regarded  and  treated  as 
such  by  the  surgeon.  Tension  is  always  a  harmful  element  in  a 
wound,  as  it  is  not  only  a  source  of  pain,  but  it  also  exerts  a  deleteri- 
ous influence  on  the  circulation  and  nutrition  of  the  tissues  upon 
which  we  must  depend  in  effecting  a  repair  of  the  wound.  Our 
present  methods  of  establishing  drainage  do  not  alwa}\s  succeed  in 
preventing  harmful  tension  from  the  accumulation  of  blood  and 
serum  in  the  wound,  hence  the  necessity  of  securing  complete 
hemostasis  before  suturing  a  wound.  Few,  if  any,  open  wounds 
are  absolutely  aseptic.  Living  tissues  exercise  a  certain  degree 
of  inhibitor}'  influence  on  a  limited  number  of  pathogenic  bacteria. 
On  the  other  hand,  extravasated  blood  serves  the  purpose  of 
a  nutrient  medium,  and,  as  such,  becomes  an  important  indirect 
cause  of  infection.  The  most  important  hemostatic  resource  in  the 
possession  of  the  surgeon  of  to-day  is  the  aseptic  ligature. 

Aseptic  Ligature. — To  Ambroise  Pare(  i  5  1 7— i  590) surgery  owes 
a  great  debt  of  gratitude,  not  as  the  discoverer,  but  as  the  first  and 
most  devoted  champion  of  the  ligature.  Through  his  influence  and 
untiring  zeal  the  ligature  gradually  found  its  way  into  popular  favor, 
and  displaced  the  barbarous  treatment  by  styptics  and  cautery.  He 
applied  the  ligature  with  the  aid  of  a  needle,  and  purposely  included 
more  or  less  of  the  soft  tissues  surrounding  the  vessel,  with  the  idea  of 
securing  a  better  hold  for  the  ligature,  and  thus  guarding  more  suc- 
cessfully against  secondary  hemorrhage.  He  removed  the  ligature 
as  soon  as  healthy  granulations  covered  the  exposed  portion  of  the 
ves.sel.  He  used  the  ligature  with  a  view  simply  to  approximate 
the  inner  walls  of  the  vessel  for  a  sufficient  length  of  time  to  enable 
union  to  take  place,  when  its  further  presence  was  considered  use- 
less and  even  detrimental.  Later,  the  direct  ligature  came  into 
general  use.  Besides  this  change,  no  great  innovations  were  made 
in  the  preparation  or  use  of  the  ligature  until  the  epoch-making 
researches  of  Joseph  Lister,  thirty  years  ago.  The  old  septic  liga- 
ture did  its  deadly  work  for  more  than  three  hundred  years.  It  is 
within  the  memory  of  many  surgeons  who  are  active  to-day  when 
the  ligature  was  expected  to  become  eliminated  spontaneously  in 
the  course  of  two  or  three  weeks  or  had  to  be  removed  by  surgical 
intervention.  As  long  as  the  ligature  remained  in  the  tissues  the 
patient  was  in  danger  of  secondary  hemorrhage.  Every  surgeon 
of  the  Civil  War  is  painfully  aware  of  the  freciuency  with  which 
secondary  hemorrhage  occurred  after  gunshot  injuries  or  after  any 
capital  operation.  A  certain  anK)unt  of  supj)uration  was  always 
7 


g3  TREATMENT    OF    HEMORRHAGE. 

necessary  for  the  spontaneous  elimination  of  the  ligature,  and  the 
septic  processes  incident  to  such  an  occurrence  always  interfered 
with  ideal  obliteration  of  the  ligated  vessel  and  healing  of  the  wound 
by  primary  intention,  and,  besides,  brought  with  it  the  dangers  of 
secondary  hemorrhage,  sepsis  and  pyemia.  Billroth  reported  23 
cases  of  ligation  of  large  arteries  after  gunshot  wounds,  and  of  this 
number  secondary  hemorrhage  occurred  in  7,  or  30.4  per  cent. 
Porta  collected  600  cases  of  ligation  of  large  arteries,  and  of  this 
number  75,  or  12.5  per  cent,  were  followed  by  secondary  hemor- 
rhage. Pilz  has  published  a  table  of  ligation  of  the  common  carotid 
artery  where  the  operation  was  done  i  58  times  for  hemorrhage  ;  of 
these  cases  35,  or  33.5  per  cent.,  suffered  from  secondary  hemor- 
rhage, which  proved  fatal  in  16,  or  15  per  cent.  How  different  the 
results  to-day!  We  have  lost  all  fear  of  ligating  veins,  which 
terrorized  surgeons  as  long  as  the  septic  ligature  was  in  use.  An 
artery  is  ligated,  the  ligature  is  cut  short,  the  wound  heals  by 
primary  union,  and  permanent  obliteration  of  the  ligated  portion  of 
the  vessel  is  the  rule,  and  secondary  hemorrhage  almost  unknown. 
The  aseptic  ligature,  wherever  and  whenever  it  can  be  applied,  has 
almost  entirely  displaced  all  other  hemostatic  agents,  and  is  now 
universally  acknowledged  as  the  safest  and  most  reliable  measure 
in  securing  provisional  and  definitive  closure  of  arteries  and  veins. 
Like  all  important  improvements,  it  has  met  with  opposition,  but  a 
more  extended  trial  has  silenced  criticism. 

In  his  first  communication  to  the  profession  on  this  subject 
Lister  alludes  to  the  advantages  of  the  aseptic  ligature  as  follows  : 
"  If  the  antiseptic  ligature  be  employed,  it  merely  inflicts  a  wound 
or  injury  upon  the  vessel,  without  introducing  any  permanent  cause 
of  irritation.  The  injured  part,  therefore,  becomes  repaired  after 
the  manner  of  a  subcutaneous  wound,  without  passing  through  the 
process  of  granulation  and  suppuration  which  is  induced  by  the 
employment  of  the  ordinary  septic  ligature."  It  may  now  be  truly 
said  that  some  form  of  aseptic  ligature  is  used  at  present  by  almost 
every  surgeon,  and  that  while  the  merits  of  the  aseptic  treatment  of 
wounds  are  still  questioned  by  a  few,  no  one  conversant  with  mod- 
ern surgery  would  use  the  ordinary  ligature  without  a  sense  of 
neglect  or  actual  guilt.  Perhaps  no  other  surgical  procedure  has 
ever  enjoyed  the  confidence  of  the  whole  profession  throughout 
the  civilized  world  to  the  same  extent  as  the  aseptic  ligature.  This 
universal  faith  in  the  reliability  and  safety  of  the  aseptic  ligature  is 
only  a  natural  outgrowth  of  the  superior  results  following  its  use. 
Protracted  suppuration  in  wounds,  the  result  of  retained  ligatures, 
secondary  hemorrhage,  and  suppurative  inflammation  of  the  li- 
gated vessels  and  its  many  immediate  and  remote  complications 
have  almost  entirely  disappeared  under  the  use  of  the  aseptic  liga- 
ture. Nussbaum  has  well  said  :  "  Catgut  is  without  doubt  Lister's 
greatest  discovery."  And,  again  :  "  How  pleasant  it  is  to  cut  the 
ligatures  short  and   leave  them  unconcerned  to  their   fate  in  the 


ASEPTIC    LIGATURE.  99 

wound  !  In  ovariotomies,  etc.,  their  value  can  not  be  overestimated. 
The  manner  in  which  catgut  adheres  to  an  artery,  forming  connec- 
tions with  it  and  the  surrounding  tissues,  assisting  at  the  same  time 
in  forming  a  firm  ring  around  the  coats  of  the  vessel,  is  an  ex- 
ceedingly welcome  occurrence,  guarding  against  secondary  arterial 
hemorrhage  in  ligating  in  the  continuity  of  a  vessel,  and  rendering 
even  the  application  of  a  ligature  in  close  proximity  to  a  large  col- 
lateral branch  devoid  of  danger.  All  this  silk  can  not  do."  Be- 
fore the  introduction  of  antiseptic  surgery  suppuration  at  the  seat 
of  ligation  was  almost  a  necessity.  As  suppuration  interfered  seri- 
ously with  the  hyperplastic  processes  in  the  tissues  of  the  arterial 
tunics,  secondary  hemorrhage  was  of  frequent  occurrence,  because 
the  adhesions  between  the  surfaces  of  the  intima  were  not  always 
sufficiently  firm  to  resist  the  intra-arterial  pressure  at  the  time  of 
the  separation  of  the  ligature.  On  this  account  it  was  deemed  ab- 
solutely neces.sary  by  the  older  surgeons,  in  deligating  an  artery  in 
its  continuity,  to  apply  the  ligature  at  least  an  inch  distant  from  the 
next  collateral  branch,  so  as  to  secure  a  thrombus  of  sufficient 
length  to  resist  the  blood  pressure.  But  the  length  of  the  throm- 
bus did  not  always  protect  the  patient  against  secondary  hemor- 
rhage, as  the  septic  endarteritis  left  the  thrombus  loose,  which,  on 
cutting  througli  of  the  ligature,  was  only  too  often  swept  away 
before  the  blood  current. 

Ligating  a  blood-vessel  under  strict  aseptic  precautions  presents 
the  following  advantages  :  (i)  The  ligature  remains  undisturbed  in 
the  wound,  being  either  removed  by  absorption  or  becoming  en- 
cy.sted  after  having  fulfilled  the  purpose  of  a  provisional  hemo- 
static. (2)  Speedy  obliteration  of  the  lumen  of  the  vessel  takes 
place  by  proliferation  of  new  tissue  from  the  endothelial  and  con- 
nective-tissue cells,  independently  of  thrombus  formation  ;  in  fact, 
thrombosis  is  often  wanting.  The  constricted  portion  of  the  ves- 
sel does  not  necrose  ;  it  is  infiltrated,  like  the  catgut,  with  living 
tissue.  In  all  operations  with  the  aseptic  ligature  the  small  size 
of  the  intravascular  clot  and  its  total  absence,  as  is  frequently 
noted,  are  in  remarkable  contrast  with  the  results  observed  after 
the  use  of  the  ordinary  septic  ligature. 

The  importance  of  the  thrombus  as  an  active  agent  in  the  de- 
finitive closure  of  vessels  has  vanished  before  the  brilliant  results 
obtained  with  the  aseptic  ligature.  The  safety  of  the  aseptic  liga- 
ture does  not  depend  on  rupturing  the  intima,  as  was  claimed  for 
the  ordinary  ligature.  All  that  is  required  of  the  aseptic  ligature 
in  the  way  of  a  mechanical  agent  to  insure  obliteration  of  a  blood- 
ves.sel  is  to  approximate  and  hold  in  contact  the  intact  intima  for  a 
sufficient  length  of  time  for  the  definitive  closure  to  be  effected  by 
the  formation  of  a  minute  transverse  scar  immediately  underneath 
or  in  close  proximity  to  the  ligature,  and  firm  enough  to  resist 
the  blood  {ircssure.  More  than  ten  years  ago  I  demonstrated,  by 
a  long  .series  of  experiments   on   different  animals,  that  a  reliable 


lOO 


TREATMENT    OF    HEMORRHAGE. 


Fig.  45. — Specimen  in  experiment  No.  4. 


intravascular  scar  will  form  in  a  very  few  days  independently  of  the 
formation  of  a  thrombus.  In  one  series  of  expenments  cicatricial 
obliteration  of  blood-vessels  between  two  ligatures  was  studied, 
emptying   the  intervening  portion  of  the  blood-vessel  completely 

of  the  contents.  In  all  these 
experiments  the  vessel  sheath 
was  always  laid  open  to  the 
extent  of  an  inch  or  more, 
and  the  artery  or  vein  com- 
pletely isolated  to  the  same 
distance,  when  two  ligatures 
were  placed  underneath  the 
vessel.  The  proximal  end  of 
the  artery  was  tied  first,  and 
the  distal  side  of  veins.  The 
vessel  was  made  bloodless  by 
placing  the  second  ligature  in  close  contact  with  the  first,  and  by 
making  traction  on  both  ends,  and  sliding  the  loop  to  the  required 
distance,  when  the  return  of  blood  was  prevented  by  an  assistant 
who  compressed  the  vessel  firmly  between  the  thumb  and  index- 
'finger  until  the  ligature  was  tied.  If  any  doubt  remained  as  to  the 
bloodless  condition  of  the  intervening  space,  these  manipulations 
were  repeated  before  tying  the  second  ligature.  In  tying  the  liga- 
tures it  was  the  aim  not  to  injure  the  intima,  but  simply  to  approxi- 
mate its  inner  surfaces.  The  ligatures  were  usually  applied  about 
half  an  inch  apart.  From  the  man}^  experiments  made,  only  three 
will  be  cited. 

"  Experiment  ^. — Right  femoral  artery  of  sheep  tied  with  coarse 
catgut.  Animal  killed  seven  days  after  operation.  Proximal 
thrombus  extending  to  next  collateral  branch,  three-fourths  of  an 
inch  above  the  ligature  ;  nonadherent  and  only  partly  filling  the 
lumen  of  the  vessel.  Distal  thrombus  minute.  Intervening  por- 
tion of  vessel  filled  with  an  adherent  mass  of  granulations. 

"  Ligatures  softened  and  cov- 
ered by  granulation  tissue.  On 
removing  central  ligature,  lumen 
of  vessel  was  found  to  be  com- 
pletely and  firmly  obliterated 
by  direct  adhesions  between  the 
granulating  surfaces  of  the  in- 
tima (Fig.  45)." 

This  experiment  would  tend 
to  prove  that  the  lumen  of  an 

artery  the  size  of  the  femoral  is  securely  obliterated  between  two 
ligatures  in  seven  days,  without  the  intervention  of  a  blood-clot. 
Single  ligations  of  vessels  of  similar  size  have  shown,  after  the 
lapse  of  the  same  time,  a  minute  intravascular  scar  at  the  point  of 
ligation  firm  enough  to  resist  the  intra- arterial  pressure. 


Fig.  46. — Specimen  in  experiment  No.  18  ; 
a.  Obliterated  vessel ;  b,  cross-section. 


INTRAVASCULAR    CICATRIZATION    AFTER    LIGATION. 


lOI 


Fig.  47. — Specimen  in  experiment  No. 
vessel ;  b,  cross-section. 


Obliterated 


"  Expcrb)ient  18. — Left  femoral  artery  of  sheep  tied  with  coarse 
braided  silk.  Distal  ligature  just  above  profunda.  Animal  killed 
fifty  da\'s  after  operation.  Ligatures  encysted.  On  the  proximal 
side  the  artery  was  obliterated  to  a  distance  of  one-eighth  of  an 
inch  above  the  ligature.  Profunda  pervious.  Intervening  portion 
converted  into  a  solid  cord  of  connective  tissue  in  which,  on  trans- 
verse section,  the  remains  of  the  artery  could  still  be  recognized 
(Fig.  46)." 

The  same  speedy  process  of  definitive  obliteration  of  the  lumen 
of  the  veins  takes  place  after  exclusion  of  the  blood  for  a  limited 
period  of  time,  as  is  shown  by  the  following  experiment : 

"  Experiuioit  ^8. — Double  ligation  of  the  internal  jugular  vein 
of  sheep,  intervening  empty  portion  an  inch  in  length.  Silk 
ligatures  were  re- 
moved three  days 
after  operation. 
Animal  killed 
twent}'-seven  days 
after  ligation.  Cir- 
culation arrested  at 
seat  of  ligatures. 
Peripheral  clot 
narrow,  partially 
adherent,  one  inch 

in  length.      At  the  seat  of  operation  about  two  lines  of  the  vessel 
converted  into  a  solid  string  of  connective  tissue  (Fig.  47)." 

Intravascular  Cicatrization  after  Ligation. — I  found,  in  my 
experiments  on  arteries,  that  in  thirty-four  cases  the  presence  of 
a  proximal  thrombus  is  mentioned  thirty-one  times,  against  ten 
in  the  distal  portion  of  the  arteiy.  Li  four  of  the  experiments  it  is 
noted  that  only  a  peripheral  thrombus  formed  in  seven  cases,  in 
which  the  thrombus  was  found  only  on  the  proximal  side  of  the 
ligature.  In  most  of  the  cases  the  thrombus  was  quite  minute, 
seldom  filling  the  entire  lumen  of  the  vessel,  and  never  adherent  to 
the  intima.  A  notable  exception  was  afforded  by  the  experiment 
on  a  horse,  where  an  immense  proximal  and  distal  thrombus  formed 
in  the  right  common  carotid  artery,  filling  the  entire  lumen  of  the 
vessel,  extending  on  the  proximal  side  to  near  the  subclavian  artery, 
and  on  the  peripheral  to  beyond  the  bifurcation  of  the  vessel.  In 
the  specimens  derived  from  twenty-one  experiments  on  veins  I 
was  never  able  to  find  even  a  trace  of  a  thrombus  on  the  prox- 
imal side  of  the  ligature,  while  the  presence  of  a  distal  thrombus 
was  noted  eleven  times,  or  in  a  little  more  than  50  per  cent,  of  all 
the  cases. 

These  experiments  furnished  the  most  favorable  opportunities 
to  study  the  process  of  cicatrization  underneath  the  proximal  liga- 
ture, independently  of  a  thrombus,  as  the  presence  of  a  clot  was 
excluded  in  every  instance.     With  the  exception  of  the  specimen 


I02  TREATMENT    OF    HEMORRHAGE. 

obtained  from  the  horse,  the  thrombi  in  veins  were  usually  small  in 
size  and  seldom  adherent  over  any  considerable  surface.  Only  in 
exceptional  cases,  both  in  arteries  and  veins,  did  the  thrombus  reach 
as  far  as  the  nearest  collateral  branch.  The  results  of  these  experi- 
ments make  it  obvious  that  the  time-worn  rule  laid  down  in  most 
of  our  text-books  on  surgery  of  but  a  few  years  ago,  which  directs 
the  operator  to  apply  the  ligature  in  such  a  manner  as  to  leave  a 
space  of  one  inch  or  more  between  the  ligature  and  the  nearest  col- 
lateral branch  for  the  purpose  of  insuring  the  formation  of  a  throm- 
bus, is  wrong,  both  in  theory  and  practice,  and  should  no  longer  be 
observed  as  a  guide  in  deciding  upon  the  point  for  ligation.  The 
aseptic  absorbable  ligature  can  be  applied  near  a  collateral  branch 
without  incurring  any  risk  whatever  of  secondary  hemorrhage,  pro- 
vided the  wound  is  aseptic  and  remains  so  after  the  operation.  The 
first  attempt  at  obliteration  of  a  blood-vessel  after  ligation  is  mani- 
fested in  the  connective  tissue  of  the  adventitia  and  the  paravascular 
connective  tissue.  As  early  as  twenty -four  hours  after  ligation  the 
isolated  portion  of  the  vessel  between  the  two  ligatures  has  become 
adherent  to  the  surrounding  tissues,  and  the  swollen  adventitia 
overlaps  and  hides  the  loop  of  the  ligature.  The  connective  tissue 
becomes  very  vascular,  and  undergoes  rapid  transformation  into 
embryonic  tissue,  being  converted  in  a  few  days  into  granulation 
tissue,  which  completely  surrounds  and  embraces  the  ligatures,  the 
intervening  portion,  and  the  vessel  ends  very  much  in  the  same 
manner  as  the  provisional  callus  incloses  the  ends  of  a  fractured 
bone. 

This  investing  capsule  of  new  connective  tissue  was  found 
present  in  every  specimen,  and  in  many  instances  was  of  remark- 
able size  and  strength.  The  thickest  portion  of  this  paravascular 
capsule  always  corresponded  to  the  locality  which  had  been  sub- 
jected to  the  greatest  amount  of  traumatism — that  is,  the  side  of 
the  vessel  toward  the  incision.  As  soon  as  definitive  closure  of  the 
vessel  had  taken  place  the  capsule  diminished  in  size,  until,  after  a 
period  of  three  months,  it  did  not  exceed  the  diameter  of  the  ligated 
vessel. 

The  contraction  that  belongs  to  all  cicatricial  tissue  manifests 
itself  also  in  the  spindle-shaped  mass  of  connective  tissue  which 
forms  around  vessels  after  ligation,  and  renders  material  assistance 
in  the  process  of  final  obliteration  by  compressing  the  vessel,  thus 
diminishing  its  lumen.  In  all  my  experiments  in  which  union 
of  the  incision  occurred  without  suppuration  the  intervening  por- 
tion of  the  vessel  was  found  covered  by  granulation  tissue  as 
early  as  the  third  day,  and  the  fibrous  capsule  was  always  firmly 
adherent  to  the  vessel.  Through  the  medium  of  this  connective- 
tissue  capsule  the  ligated  ends  of  the  vessel  always  formed  firm 
adhesions  with  the  surrounding  structures,  the  artery,  vein,  and 
nerve  often  being  enveloped  by  one  common  capsule,  as  may  be 
seen  well  illustrated  in  figure  48. 


INTRAVASCULAR    CICATRIZATION    AFTER    LIGATION. 


103 


The  process  of  repair  initiated  in  the  adventitia  proceeds  by- 
continuity  of  tissue  in  a  central  direction  toward  the  lumen  of  the 
vessel,  until  the  connective-tissue  proliferation  perforates  the  endo- 
thelial lining  of  the  intima,  an  event  which  initiates  the  formation 
of  the  endo\ascular  cicatrix.  Simultaneously  with  the  appearance 
of  the  granulation  process  in  the  intima  and  the  appearance  of  new 
vessels  from  the  adventitia  the  endothelial  cells  assume  an  active 
part  in  the  process  of  cicatrization,  the  new  tissue  elements  ming- 
ling with  the  connective-tissue  product  and  assisting  them  in  the 
formation  of  the  internal  or  definitive  scar.  Cicatrization  begins 
always  underneath  and  in  the  immediate  vicinity  of  the  ligature. 
This  fact  receives  a  satisfactory  explanation  by  assuming  that  the 
greatest  amount  of  traumatism  is  inflicted  at  this  point,  and  that, 
by  interruj^ting  the  circulation  in  the  vasa  vasorum  by  the  liga- 
ture, an  active  engorgement  is  produced  which  accelerates  tissue 
changes  and  the  formation  of  new  vessels.  At  the  same  time  the 
inner  surfaces  of  the  intima  are  here  brought  into  accurate  and 
uninterrupted  con- 
tact. 

In  my  experi- 
ments on  arteries 
three  days  was  the 
shortest  period  of 
time  in  which  a  nar- 
row, firm  cicatrix 
formed  underneath 
the  proximal  liga- 
ture. In  the  experi- 
ments on  veins  the 
condition  of  the  ves- 
sel was  always  examined  underneath  the  proximal  ligature,  inas- 
much as  any  changes  in  the  tunics  and  lumen  of  the  vessel  at  this 
point  had  to  be  attributed  to  the  tissues  themselves,  independently 
of  a  blood-clot,  as  the  intervening  portion  was  always  made  blood- 
less, and  a  thrombus  was  never  found  on  the  proximal  side  of  the 
ligature.  In  one  of  the  specimen  I  found,  on  the  fifth  day,  a  firm, 
circular  cicatrix  underneath  the  ligature.  The  intervening  portion 
of  the  vessel  was  carefully  examined  at  times  ranging  from  six 
hours  to  ninety  days  after  the  operation.  This  ])ortion  of  the  ves- 
sel, although  deprived  of  all  vascular  supply,  never  necrosed  unless 
suppuration  followed  the  operation.  Nutrition  was  derived  from 
the  paravascular  tissues  until  the  interrupted  circulation  in  the  vasa 
vasorum  was  restored,  when  the  vessel  tunics  were  again  brought 
into  a  condition  capable  of  assuming  active  tissue  proliferation.  In 
many  of  the  specimens  it  was  noted  that  the  walls  of  the  interven- 
ing portion  were  found  thickened,  which  would  certainly  indicate 
that  the  tissues  did  not  remain  in  a  passive  condition,  but  were 
actively  concerned  in  the  work  of  tissue  proliferation. 


Fig.  48. — Common  fibrous  capsule  for  obliterated  artery 
[ii),  vein  (7'),  and  nerve  (w). 


I04 


TREATMENT    OF    HEMORRHAGE. 


The  earliest  time  at  which  granulation  tissue  was  found  upon  the 
free  surface  of  the  intima  was  seven  days  in  the  case  of  arteries, 
and  three  days  in  veins.  The  formation  of  the  cicatrix  in  the  lumen 
of  the  vessel  always  began  near  the  ligatures,  the  material  filling 
the  folds  of  the  intima  often  forming  distinct  bridges  connecting  the 
highest  points  of  adjacent  ridges.  The  amount  of  granulation 
material  in  the  lumen  of  the  vessel  appeared  to  vary;  in  some 
specimens  the  lumen  presented  a  stellate  shape,  the  surfaces  of  the 
intima  adherent,  with  a  minimum  amount  of  new  tissue  between  them, 
while  in  other  specimens  a  cylindric  mass  of  new  connective  tissue 
occupied  the  interior  of  the  vessel.      Complete  obliteration  of  the 


Intima 


Partly  formed  connective 
tissue  from  endothelia. 


Proliferated 
connective 
tissue  in 
lumen. 


Endothe-  ,. 
Hal  pTo-^^~_^ — 
lifera-  ^^ 

tion. 


Fig-  49- — Cross-section  of  obliterated  artery,  exhibiting  the  histologic  appearances  of  the 
intravascular  scar  (X  240). 

intervening  portion  took  place  in  the  femoral  artery  in  thirty-five 
days,  in  the  carotid  in  thirty-nine  days,  and  in  the  internal  jugular 
vein  in  twelve  days. 

As  cicatrization  advances  the  original  structures  of  the  tunics 
disappear,  the  endothelia  are  transformed  into  connective  tissue,  and 
between  the  paravascular  cicatrices  the  elastic  and  muscular  tissues 
undergo  degeneration  and  are  ultimately  removed  by  absorption. 

The  final  effects  of  the  ligature  are  obliteration  of  the  lumen 
and  conversion  of  all  the  tunics  of  the  vessel  into  a  solid  cord 
of  connective  tissue,  which,  again,  is  subject  to  various  degrees 
of  atrophy.     The  histologic  processes  of  endovascular  cicatrization 


INTRAVASCULAR    CICATRIZATION    AFTER    LIGATION. 


105 


in  my  experimental  work  were  studied  by  making  transverse 
sections  through  the  intervening  portion,  equidistant  from  the  hg- 
atures. 

Figure  49  represents  the  inner  border  of  the  wall  of  the  femoral 
artery  and  a  part  of  its  lumen.  The  open  lumen  of  a  vas  vasorum 
can  be  seen  near  the  intima.  From  the  intima  projections  of  con- 
nective-tissue proliferation  are  seen  to  penetrate  into  the  lumen  of 
the  vessel,  pushing  before  them  the  endothelial  lining,  and  perfora- 
ting it  at  different  points,  subsequently  forming  a  network  of  con- 
nective tissue  in  the  interior  of  the  vessel.  In  the  meshes  of  this 
network  are  seen  masses  or  nests  of  new  endothelial  cells,  products 
of  the  preexisting  endothelial  cells.      At  certain  places  these  new 


Prolifera- 
tion of 
connec- 
tive tis- 
sue. 


Endothe- 
lial pro- 
lifera- 
tion. 


Fig.  50- — Histologic  structure  of  intravenous  scar,  right  internal  jugular  vein,  forty-nine 
days  after  ligation.     Transverse  section  between  ligatures  (X  240). 

endothelial  cells  present  an  oval  or  spindle-shaped  form,  assumed 
during  their  transformation  into  connective  tissue.  The  vasa  vaso- 
rum send  blood-vessels  into  the  lumen,  filled  with  embryonic  tissue 
in  various  stages  of  development. 

Figure  50  shows  the  intima  and  a  portion  of  the  granulation 
thrombus  which  has  permanently  closed  the  lumen  of  the  vessel. 
The  microscopic  appearances  are  almost  identical  with  those  of  the 
arterial  specimen.  Both  of  these  illustrations  furnish  the  best  pos- 
sible demonstration  of  the  manner  in  which  the  intravascular  cica- 
trix is  formed  from  the  connective  tissue  and  endothelia.  The  ma- 
croscopic and  microscopic  examinations  of  the  specimens  seem  to 
demonstrate  in  a  most  conclusive  manner  that  the  intravascular  scar 


I06  TREATMENT    OF    HEMORRHAGE. 

after  ligation  is  the  exclusive  product  of  connective  tissue  and  endo- 
thelial proliferation.  A  detailed  account  of  the  obliterative  pro- 
cesses following  ligation  of  blood-vessels  has  been  given,  but  I  deem 
an  accurate  and  comprehensive  knowledge  of  this  subject  essential 
to  a  proper  appreciation  of  the  purpose  and  uses  of  the  ligature. 

Ligature  Material. — The  results  of  my  experiments,  as  well  as 
the  literature  on  the  subject,  tend  to  prove  that  all  kinds  of  liga- 
tures, provided  they  have  been  made  aseptic,  always  become  en- 
cysted in  aseptic  wounds.  All  ligatures,  however,  that  perma- 
nently resist  absorption  destroy  the  continuity  of  the  vessel,  and 
on  this  account,  instead  of  adding  strength  to  the  paravascular 
cicatrix,  weaken  the  vessel-wall  at  the  seat  of  ligation.  I  have 
never  observed  a  single  instance  in  hospital  or  private  practice 
where  the  catgut  ligature  failed  to  fulfil  in  the  most  satisfactory 
manner  the  purposes  of  a  provisional  hemostatic  agent  until  the 
definitive  cicatrix  had  become  sufficiently  firm  to  resist  the  intra- 
arterial pressure.  In  place  of  severing  the  tunics  of  the  ligated 
vessel,  the  catgut  ligature  is  gradually  displaced  by  living  tissue 
which  increases  the  resisting  capacity  of  the  vessel,  providing  an 
additional  safeguard  against  secondary  hemorrhage,  if  from  any 
cause  definitive  obliteration  is  retarded. 

In  enumerating  the  superior  advantages  of  the  catgut  ligature 
Nussbaum  says  :  "  The  most  careful  microscopic  examinations 
have  shown  that  catgut  increases  to  a  considerable  degree  the  resist- 
ing power  of  an  artery  in  forming  firm  connective-tissue  connections 
with  the  vessel."  The  fibers  of  the  catgut  are  infiltrated  with  cells 
in  two  or  three  days,  and  in  the  course  of  two  to  four  weeks  the 
ligature  is  removed  by  absorption  and  a  ring  of  living  tissue  takes 
its  place.  Catgut  is  the  material  usually  employed  as  an  absorb- 
able ligature.  Some  surgeons  prefer  kangaroo  tendon,  but  there  is 
no  special  advantage  in  using  this  material.  Dr.  H.  O.  Marcy  has 
spent  much  time  and  used  his  genius  in  perfecting  the  preparation 
of  kangaroo  tendon  and  in  introducing  it  for  general  use,  but  cat- 
gut has  stood  the  test  of  time  and  experience  and  will  retain  its  well- 
deserved  place  in  surgery  and  command  the  confidence  of  the  pro- 
fession. The  two  kinds  of  ligature  material  now  in  general  use  are 
the  animal  absorbable  ligature  and  silk. 

Sterilization  of  Silk, — Many  prominent  surgeons,  after  an 
unfavorable  experience  with  catgut,  have  gone  back  to  the  use  of 
silk  as  a  ligature  material.  The  most  influential  champion  of  the 
silk  ligature  at  the  present  time  is  Kocher.  He  abandoned  the  use 
of  catgut  a  number  of  years  ago  because,  with  all  the  care  that 
could  possibly  be  taken  in  its  preparation  and  use,  many  of  the 
wounds  suppurated,  and  he  was  able  to  trace  the  source  of  infection 
to  the  catgut.  He  now  uses  silk  exclusively,  and  after  an  exten- 
sive experience  is  satisfied  with  the  results.  Kocher  sterilizes  silk 
by  first  immersing  it  in  ether  for  twenty-four  hours  for  the  purpose 
of  removing  the  fat,  after  which  it  is  boiled  for  twenty  minutes  in  a 


STERILIZATION    OF    CATGUT. 


107 


solution  of  corrosive  sublimate,  i  :  1000.      As  an  extra  precaution 
he  reboils  it  for  ten  minutes  before  every  operation.      The  removal 


51 


9         «  76543 

-Showing  the  approximate  sizes  of  both  twisted  and  braided  silk. 


of  fat  may  be  an  advantage  in  preparing  the  silk  for  sterilization  by 
boiling,  but  it  is  not  essential. 

Silk  can  be  rendered  sterile  by  exposing  it  to  the  action  of  steam 
under  high  pressure  for  twenty  minutes,  or  by  boiling  for  thirty 
minutes  in  a  normal  salt  or  soda  solution.  It  can  be  kept  sterile 
and  ready  for  use  in  absolute  alcohol.  It  should  be  wound  on 
glass  plates  with  the  sharp  margins  ground  off,  and  be  at  least  six 
inches  in  length.  In  hospitals  and  for  office  use 
glass  jars  with  reels  are  convenient  for  the  pre- 
servation of  the  silk  ligatures.  F"or  emergency 
use  the  silk  can  be  carried  in  sealed  sterile  en- 
velops of  convenient  size. 

Sterilization  of  Catgut. — The  sterilization  of 
catgut  has  occupied  the  time  and  attention  of 
bacteriologists  and  surgeons  since  Lister's  first 
efforts  by  immersion  in  carbolized  oil.  It  is  safe 
to  state  that  notwithstanding  the  great  improve- 
ments which  have  been  made,  the  process  is  still 
far  from  being  perfect.  Lister's  crude  method 
of  rendering  catgut  aseptic  has  been  variously 
modified  during  the  last  thirty  years.  Different 
methods  have  been  devised,  and  nearly  all  anti- 
septic substances  have  been  employed  in  the 
preparation  of  catgut.  The  very  fact  that  so 
many  different  methods  have  been  recommended 
is  the  very  best  and  most  convincing  proof  that 
none  of  them  has  proved  entirely  satisfactory. 
Kocher  abandoned  the  use  of  his  juniper  catgut. 
Carbolized,  sublimated,  and  chromicized  catgut 
have  been  u.sed  very  extensively,  but  every  sur- 
geon knows  from  actual  experience  that  not  in- 
frequently wound  infection  can  be  traced  to  imperfect  sterilization 
of  the  material.  Dry  sterilization  of  catgut  .seemed  to  become  the 
general  {jroccdure  a  few  years  ago,  but  extensive  trial  has  shown 
that  it  can  not  be  relied  upon  in  rendering  the  material  absolutely 
safe  for  practical  use. 


Fif^.  52. —  Iruax's 
bottle  containing 
three  sizes  of  catgut. 


io8 


TREATMENT    OF    HEMORRHAGE. 


The  many  failures  of  catgut  as  an  aseptic  suture  and  ligature 
material  as  heretofore  prepared  are  responsible  for  the  substitution 
of  silk  for  catgut  in  the  practice  of  many  surgeons.  Silk  can  be 
readily  sterilized  by  boiling,  the  simplest  and  quickest  method  of 
effecting  absolute  sterilization.  The  use  of  the  absorbable  animal 
ligature  presents  so  many  advantages  over  silk  that  all  that  is 
necessary  to  take  its  place  permanently  is  a  reliable  method  of  ster- 
ilization. The  ideal  sterilization  of  catgut  consists  in  rendering  the 
material  not  only  absolutely  sterile,  but  also  mildly  antiseptic,  with- 
out impairing  its  tensile  strength.  Every  surgeon  has  been 
anxiously  looking  for  a  method  by  which  catgut  could  be  prepared 
so  that  it  could  be  sterilized  by  boiling  without  impairing  its 
strength.  Fortunately,  this  expectation  has  been  realized.  Experi- 
ments have  shown  that  catgut  and  leather  immersed  for  forty-eight 
hours  in  a  2  to  4  per  cent,  solution  of  formalin  undergo  an  un- 
known chemic  change  which  alters  their  texture  in  such  a  way 
that  the  tensile  strength  is  not  impaired,  but  rather  increased,  by 


Fig-  53- — Ignition  tube  with  ligatures  wound  on  bobbins. 


Fig-  54- — Ignition  tube  with  ligatures  wound  on  spools. 


boiling.  The  commercial  catgut  is  subjected  to  the  action  of  for- 
malin without  any  previous  preparatory  treatment  of  the  raw 
material. 

Hofmeister's  Method. — Hofmeister,  who  has  done  such  excel- 
lent service  in  perfecting  the  formalin  preparation  of  catgut,  gives 
the  following  most  recent  method  : 

1.  The  catgut  is  wound  on  a  glass  plate  with  slightly  projecting 
edges,  so  that  the  gut  is  free  from  the  sides  of  the  plate  and  ex- 
posed to  the  circulation  of  the  boiling  and  flowing  water.  The 
ends  of  the  gut  are  fastened  through  holes  in  the  plate. 

2.  Immersion  for  from  twelve  to  forty-eight  hours  in  aqueous 
solution  of  formalin,  2  to  4  per  cent. 

3.  Immersion  in  flowing  water  for  at  least  twelve  hours  to  free 
the  gut  from  the  formalin. 

4.  Boiling  in  water  for  from  ten  to  thirty  minutes.  Ten  to 
twelve   minutes    answer   the   purpose   fully,   as  all   microbes   and 


STERILIZATION    OF    CATGUT.  IO9 

spores  are  destroyed  by  exposure  to  boiling  heat  for  that  length  of 
time. 

5.  Hardening  and  preservation  in  absolute  alcohol  contain- 
ing 5  per  cent,  of  glycerin  and  yL-  of  i  per  cent,  of  corrosive  subli- 
mate. Experiments  on  animals  have  proved  that  catgut  thus  pre- 
pared is  absorbable,  though  not  so  quickly  as  the  ordinary  material. 
One  of  the  essential  conditions  of  success  in  this  method  of  catgut 
sterilization  is  to  wind  the  gut  quite  tightly  around  the  glass  plate 
during  the  process  of  sterilization. 

Senu's  ]\Iodification  of  Hofmeister' s  Method. — The  first  attempts 
to  sterilize  catgut  by  Hofmeister's  method  under  my  own  direction 
were  made  at  St.  Joseph's  Hospital,  Chicago,  by  the  sister  in  charge 
of  the  operating  room.  The  result  of  experience  led  to  modification 
of  the  procedure  in  several  wa}'S.  Instead  of  glass  plates,  ordi- 
nary glass  abdominal  drainage-tubes  have  been  employed,  upon 
which  the  gut  is  wound  quite  tightly.  These  perforated  glass 
drains  have  been  found  an  excellent  substitute  for  the  plates.  An 
ordinary  large  test-tube  would  answer  the  same  purpose.  The 
remaining  directions  given  by  Hofmeister  were  followed  to  the  let- 
ter. Numerous  inoculations  with  fragments  of  catgut  prepared  by 
this  method  in  sterile  gelatin  invariably  gave  negative  results.  The 
catiTUt  is  as  strong  as  the  raw  material,  and  the  knot  is  less  liable 
to  unloosen  than  when  the  ordinaiy  material  is  used.  It  was  also 
found  that  the  formalin  catgut  could  be  reboiled  almost  any  number 
of  times  without  impairing  its  strength. 

Catgut  to  be  safe  should  not  only  be  absolutely  sterile,  but 
should  contain  a  sufficient  quantity  of  a  mild,  but  efficient,  antisep- 
tic to  render  it  unfit  as  a  culture-medium  for  pathogenic  microbes. 
Hofmeister  accomplishes  this  object  by  immersion  in  an  alcoholic 
solution  of  corrosive  sublimate.  Others  have  used  carbolic  acid. 
Both  of  these  antiseptics  unduly  irritate  the  tissues  and  increase  the 
primary  wound  secretion,  effects  which  can  not  fail  to  interfere  to 
a  certain  extent  with  an  ideal  healing  of  a  wound  by  primary 
intention. 

The  valuable  and  interesting  experiments  made  recently  by 
Lauenstein  leave  no  doubt  that  it  is  almost  next  to  impossible  to 
secure  an  absolutely  aseptic  condition  for  the  field  of  operation  by 
any  of  our  present  methods  of  disinfection.  We  are  forced  to 
admit  that  nearly  every  wound  inflicted  by  the  surgeon's  knife  con- 
tains some  pathogenic  microbes,  notwithstanding  that  the  strictest 
aseptic  precautions  may  have  been  carried  out.  The  experiments 
made  by  I'2wald  have  also  furnished  positive  evidence  that  sterile 
catgut  often  contains  a  sufficient  quantity  of  an  unknown  toxic 
substance,  which,  by  its  destructive  action  upon  the  cells  engaged 
in  the  regenerative  process,  transforms  them  into  pus-corpuscles, 
resulting  in  the  production  of  a  limited  aseptic  suppuration  and  the 
formation  of  sterile  pus.  Undoubtedly  man>'  of  the  stitch  abscesses 
that  occur  in  the  practice  of  painstaking  aseptic  surgeons  have  such 


no  TREATMENT  OF  HEMORRHAGE. 

an  origin.  These  experimental  researches  force  upon  us  the  con- 
clusion that  catgut  should  not  only  be  steriHzed,  but  that  it 
should  be  made  sufficiently  antiseptic  at  least  to  inhibit  the  growth 
of,  if  not  destroy,  the  pyogenic  microbes  which  enter  the  wound 
during  the  operation  or  which  may  reach  it  later  through  the  circu- 
lation. In  this  part  of  the  preparation  of  catgut  I  have  modified 
Hofmeister's  method  by  substituting  iodoform  for  the  corrosive 
sublimate. 

This  modification  I  deem  of  special  importance  in  emergency 
work,  in  which  we  must  take  it  for  granted  that  most  of  the  wounds 
are  infected.  After  boiling  the  deformalized  catgut  for  from  twelve 
to  fifteen  minutes,  it  is  cut  into  pieces  of  convenient  length,  tied  into 
small  bundles  containing  from  six  to  twelve  threads,  when  it  is  im- 
mersed and  kept  ready  for  use  in  the  following  mixture  :  Absolute 
alcohol,  950;  glycerin,  50;  iodoform  (finely  pulverized),  100  parts. 
The  alcohol  dissolves  part  of  the  iodoform.  The  bottle  containing 
the  catgut  should  be  kept  closed  with  a  well-fitting  glass  cork,  and 
should  be  shaken  well  every  few  days  to  bring  the  iodoform  into 
contact  with  the  threads.  The  catgut  can  be  kept  in  this  mixture 
for  a  long  time  without  losing  its  strength.  One  of  the  valuable 
properties  of  iodoform  applied  to  a  recent  wound  is  to  diminish  the 
amount  of  primary  wound  secretion.  It  does  not  destroy  pus- 
microbes,  but  it  inhibits  their  growth  when  present  in  limited 
numbers.  Catgut  prepared  by  this  method  has  been  in  use,  exclu- 
sively, for  nearly  two  years  in  St.  Joseph's  and  the  Presbyterian 
Hospitals,  and  in  Rush  Medical  College  Clinic,  with  the  very  best 
results. 

Kocher  s  Method. — This  method  consists  in  depriving  the  catgut 
of  its  fatty  matter  by  treatment  with  ether,  after  which  it  is  sterilized 
by  immersion  in  oil  of  juniper  for  from  two  to  twenty-four  hours, 
according  to  the  size  of  the  catgut. 

Alcohol  Sterilization. — Repin  and  Saul  rely  on  sterilization  by 
boiling  the  catgut  in  alcohol.  Schafifer  has  improved  this  method 
and  recommends  boiling  the  catgut  for  fifteen  minutes  in  a  solution 
consisting  of  i  gm.  of  corrosive  sublimate,  30  c.c.  of  water,  and 
170  c.c.  of  alcohol.  Catgut  thus  prepared  is  preserved  in  95  per 
cent,  alcohol. 

Von  Bergmann's  Method. — After  removing  the  fat  by  immersion 
in  ether  for  from  twenty -four  to  forty-eight  hours,  according  to  the 
size  of  the  gut,  place  the  gut  in  a  i  per  cent,  solution  of  corrosive 
sublimate  dissolved  in  80  parts  of  alcohol  and  20  parts  of  water, 
and  shake  the  vessel  frequently. 

Johnston's  Method. — Mr.  Johnston,  of  the  Jefferson  Hospital, 
Philadelphia,  recommends  the  following  process  : 

First,  steep  the  gut  in  the  best  ether  for  from  twenty-four  to 
forty -eight  hours,  then  transfer  it  directly  into  a  mercuric  bichlorid 
mixture,  consisting  of  40  grains  of  corrosive  sublimate  and  200 
grains   of  tartaric  acid  in  12  fluidounces  of  95   per  cent,  alcohol. 


HEMOSTATIC    FORCEPS. 


I  I  I 


Fig.  55- — Senn's  hemostatic  forceps. 


Fig.  56. — Kocher's  hemostatic  forceps. 


Fig-  57- — Tait's  hemostatic  forceps. 


Fig.  58. — Little's  hemostatic  forceps. 


112 


TREATMENT    OF    HEMORRHAGE. 


Very  fine  gut  should  not  remain  in  the  solution  longer  than  from  five 
to  seven  minutes,  the  next  size  larger  from  ten  to  fifteen  mmutes,  and 


Fjg,  jg. — Etheridge's  hemostatic  forceps. 


Fig.  60. — Halsted's  straight  artery  forceps. 


Fig.  61. — Spencer  Wells'  hemostatic  forceps. 


Fig.  62. — Luer's  hemostatic  forceps. 


Fig.  63. — Fricke's  hemostatic  forceps. 

the  two  largest  sizes  from  twenty  to  twenty -five  minutes.     Gut  thus 
prepared  is  then  kept  ready  for  use  by  immersing  it  in  a  solution 


APPLICATION    OF    LIGATURE. 


"3 


of  palladium  chlorid,  in  the  proportion  of  Jg  of  a  grain  to  a  pint  of 
alcohol.  Keen  speaks  very  highly  of  the  reliability  of  catgut  thus 
prepared. 

Horsehair  and  silkworm  gut  are  seldom  used  in  tying  blood- 
vessels, but  they  are  excellent  suture  materials  and  are  prepared  in 
the  same  manner. 

Preparation  of  Horsehair. — Wash  the  horsehair  thoroughh'  in 
hot  water  and  potash  soap.  Place  the  threads  in  line,  and  fasten  at 
one  end.  Wrap  in  gauze  and  boil  for  ten  minutes  in  a  solution  of 
carbonate  of  soda  l  per  cent.  ;  then  rinse  in  hot  water.  After  this 
process  boil  for  ten  minutes  in  clear  water.  Preserve  in  solution  of 
mercuric  alcohol  i  :  looo. 

Application  of  Ligature. — A  liberal  supply  of  hemostatic  forceps 
is  always  a  source  of  comfort  to  the  surgeon,  and  should  constitute 
the  most  important  part  of  the 
contents  of  every  emergency 
case.  A  hot  controversy  be- 
tween Koeberle  and  Pean  in 
reference  to  the  priorit}-  of 
using  hemostatic  forceps  for 
temporary  and  definitive  he- 
mostasis  finally  furnished 
enough  information  to  ac- 
credit the  former  with  the  in- 
vention. Koeberle  has  used 
his  "  pinces  hemostatiques  " 
since  1865.  Pean's  forceps 
were  not  made  until  three 
years  later.  Koeberle's  first 
jjublication  on  this  subject 
appeared  on  September  8, 
1868,  in  the  "Gazette  des 
Hopitaux." 

Of  the  many  modifications 
of  hemostatic  forceps  for  ordi- 
nary   use,    I    have   a   decided 
preference    for    Kocher's    in- 
strument.     It  is  light  and   has  a  sure  grasp.      P'or  abdominal  and 
pelvic  operations  forceps  of  special  size  and  construction  are  occa- 
sionally rc(]uired,  especially  by  surgeons   who  are  accustomed  to 
forcipressure  as  a  substitute  for  the  ligature. 

In  applying  a  ligature  to  a  wounded  blood-vessel  the  bleeding 
point  is  gra.sped  with  hemostatic  forceps,  and  the  ligature  applied 
and  tied  at  a  safe  distance  from  the  vessel  wound  to  insure  a  firm 
and  permanent  hold  (Mg.  64).  In  the  case  of  small  vessels,  espe- 
cially in  deep  wounds,  it  is  occasionally  found  impossible  to  secure 
enough  tissue  with  a  hemostatic  forceps  to  tie  the  ligature  so  that 
it  will  not  slip  after  removal  of  the  forceps.      In  such  ca.ses  the  sur- 


Fig.   64. — Showintj   the    manner  of   applying 
the  hgalure  to  cut  end  of  a  vessel  (Esniaich). 


114 


TREATMENT    OF    HEMORRHAGE. 


geon  avails  himself  of  the  old-fashioned  artery  hook  instead  of  the 
forceps  (Fig.  66).  With  the  sharp  hook  enough  tissue  is  grasped 
with  the  bleeding  vessel  so  that  on  slight  traction  a  small  cone  is 
made  and  the  ligature  thrown  around  its  base  and  firmly  tied  under 
the  instrument.  In  some  wounds  and  localities  it  is  sometimes 
difficult,  if  not  impossible,  to  tie  the  vessel  above  the  grasp  of  the 
instrument,  the  end  of  which  is  included  in  the  ligature  on  tying  it. 
It  is  in  such  cases  that  a  second  forceps  will  often  overcome  the 


Fig.  65. — Aneurysm  ligature  carrier. 


Fig.  66. — Minor  operating  tenaculum. 


mechanical  difficulties.  The  two  forceps  applied  closely  together 
are  separated  sufficiently  to  constitute  at  the  grasping  ends  a  cone 
over  which  the  ligature  readily  glides  into  its  proper  place.  On 
tying,  one  pair  of  forceps  is  removed,  and  the  ligature  is  tied  with 
the  necessary  firmness  on  the  removal  of  the  second  forceps. 

In  ligating  small  arteries  and  veins  it  is  seldom  that  Ave  are 
able  to  apply  the  direct  ligature,  more  or  less  of  the  surrounding 
tissues  being  included  in  the  grasp  of  the  forceps,  and  later  in  the 
ligature.  In  ligating  the  principal  arteries  after  amputation  above 
the  wrist-  and  ankle-joints  I  have  made  it  a  practice  to  apply  a 
double  direct  ligature.  The  artery  and  accom- 
panying vein  should  be  isolated  from  the  sur- 
rounding tissues  to  the  distance  of  one-third  or 
one-half  an  inch,  Avhen  the  artery  is  tied  sepa- 
rately at  a  safe  distance  from  the  cut  end,  and 
the  second  ligature,  including  the  vein,  is  ap- 
plied from  a  few  lines  to  one-third  of  an  inch 
higher  up.  In  this  manner  a  limited  bloodless 
space  is  secured  between  the  ligatures,  furnish- 
ing an  ideal  condition  for  speedy  obliteration 
of  the  lumen  of  the  vessel  by  intravascular 
cicatrization.  I  have  followed  this  practice  for 
fifteen  years  and  have  never  been  mortified 
by  the  occurrence  of  secondary  hemorrhage. 
In  direct  ligation  of  arteries  the  ligature  should  be  tied  only  with 
sufficient  firmness  to  approximate  the  intima  ;  it  is  needless  and 
often  harmful  to  rupture  any  of  the  tunics  of  the  vessel.  To 
accomplish  this  a  simple  square  knot  should  be  made,  as  by  so 
doing  it  is  much  easier  to  graduate  the  force  necessary  to  accom- 


Fig.  67. — Double 
ligation  of  artery  (.7),  up- 
per ligature  mcluding 
the  accompanying  vein 

(v). 


APPLICATION    OF    LIGATURE. 


H5 


plish  the  desired  object  than  by  tying  in  the  customary  manner. 
The  Hgature  ends  should  not  be  cut  too  close  to  the  knot,  as  by 
so  doing  the  knot  might  loosen  and  the  ligature  give  way. 

One  of  the  rules  invariably  given  by  authors  for  the  tying  of 
arteries  in  their  continuity  was  to  make  a  small  opening  in  the 
sheath  of  the  vessel,  just  of  sufficient  size  to  permit  passing  the 
ligature  needle  around  it.  It  was  feared  that  a  freer  opening  in  the 
sheath  and  a  more  extensive  isolation  of  the  vessel  would  lead  to 
necrosis  of  its  tunics  on  account  of  the  cutting-off  of  the  vascular 
supply.  That  this  idea  still  prevails  is  evident  from  some  of  the 
more  recent  text-books  on  surgery.  Lidell  calls  special  attention 
to  this  point  in  the  following  language  :  "The  risk  of  sloughing, 
however,  arises  mainly  from  isolating  the  artery  too  much,  or  from 
separating  it  too  extensively  from  its  sheath  while  dissecting  to 
expose  it,  or  while  preparing  to  pass  a  thread  around  it,  whereby  the 


l-fg.  68. — Manner  of  tightening  the  ligature  in  ligating  an  artery  in  its  continuity 

(MacComiac). 

minute  vessels  which  nourish  its  coats  are  too  extensively  destroyed  ; 
lience  the  dangerousness  of  pa.ssing  a  spatula  or  the  handle  of  a 
scalpel  under  the  artery,  and  of  dragging  it  out  of  its  bed  when 
t)ing  it."  These  words  of  caution  were  in  place  as  long  as  the 
septic  ligature  was  in  use.  All  these  fears  arc  luifouiidcd  when 
operating  tinder  aseptic  precautions,  with  the  eniploynient  of  the  ab- 
sorbable aseptic  ligature. 

In  experimental  work  I  isolated  the  arteries  and  veins  from 
their  sheaths  for  an  inch  or  more,  and  dragged  the  vessel  near 
to  the  surface  of  the  wound  in  applying  the  second  ligature,  and 
yet  I  never  observed  any  sloughing  except  occasionally  in  the 
cases  where  the  operation  was  followed  by  suppuration.  Much 
harm  has  been  done  by  ligating  an  artery  through  a  small  opening 
in  its  sheath.  Nerves,  veins,  ureters,  and  other  important  structures 
have   not  infrequently   been    unknowingly   and    unintentionally   in- 


Il6  TREATMENT    OF    HEMORRHAGE. 

eluded  in   the  ligation.      By   laying  the  sheath   open   freely  such 


Fig.  69. — Ligation  of  the  common  carotid  and  subclavian  arteries:  (i)  Exposure 
of  the  carotid  artery  in  the  neck.  The  sternomastoid  muscle  (A')  is  retracted  outward  ; 
the  deep  layer  of  the  cervical  fascia  {.F.i:.)  is  divided,  and  the  common  carotid  artery  (C), 
the  jugular  vein  {/),  the  vagus  nerve,  and  the  descending  branch  of  the  hypoglossal 
nerve  are  thus  brought  into  view^.  The  bifurcation  of  the  common  carotid  into  the  internal 
and  external  carotid  is  also  discernible.  The  origin  of  the  thyroid  from  the  external 
carotid,  which  in  the  illustration  is  situated  abnormally  far  outward,  has  been  freed  by 
dissection. 

(2)  Exposure  of  the  subclavian  artery  below  the  clavicle.  The  pectoralis  major 
muscle  (jP)  is  divided  in  the  direction  of  the  cutaneous  incision  to  the  deltoid  muscle  {D). 
Below  the  former  the  subclavian  artery  (A)  is  visible  between  the  vein  (  F)  and  the 
brachial  plexus  of  nerves  {-P^)  (after  Zuckerkandl). 


APPLICATION    OF    LIGATURE.  11/ 

accidents  are  avoided,  and  no  liarm  to  the  ligated  portion  of  the 


Kifj.  70. — Kxposuri-  loi  liL'aii.m  .)i  ili(  a\ill.uy  nnl  Ijracliial  arteries:  Mcb,  Coraco- 
hracliialis;  y,  inner  jjortion  of  llic  fascia  of  llic  uj;]jer  arm  ;  M,  median  nerve  ;  6V,  lesser 
internal  cutaneous  nerve  ;  Cn,  greater  internal  cutaneous  nerve  ;  Ax,  axillary  artery  ;  B, 
biceps;   J'l),  brachial  fascia;    A,  brachial  artery  ;    I'b,  brachial  vein  (after  Zuckerkandl). 


vessel  results  if  the  aseptic  ligature  is  used  and  applied  under  strict 


ii8 


TREATMENT    OF    HEMORRHAGE, 


aseptic  precautions.      The  sheath  of  the  vessel  should  be  laid  open 
freely,  so  that  the  operator  can  not  only  feel,  but  see  what  he  is 


Fig.  71. — Exposure  of  the  cubital,  radial,  and  ulnar  arteries  :  Z,  Transverse  section 
of  the  aponeurosis  of  the  biceps  muscle  ;  A,  cubital  artery  accompanied  by  veins  ;  M, 
median  nerve  ;  V,  cubital  veins  ;  Ar,  radial  artery  ;  Au,  ulnar  artery  at  the  inner  side  of 
the  tendon  of  the  internal  ulnar  muscle  {U)  (after  Zuckerkandl). 


APPLICATION    OF    LIGATURE. 


119 


doing,  for  in  pursuing  this  course  there  is  less  harm  done  than  by 
operating  in  the  dark. 

The  double  catgut  ligature  may  be  resorted  to  with  advantage 


Fie  72.— Kxi)osurc  of  the  femoral  artery.  Below  Poupart's  ligament,  m  the  opened 
sheath  of  the  vessels,  are  to  be  seen,  upon  the  median  side,  the  femoral  vem,  and  upon  its 
outer  side,  the  femoral  artery.  In  the  middle  of  the  tluKh  the  sartorn.s  muscle  (.S)  is 
drawn  outward,  the  deep  layer  of  the  fascia  being  divide.l,  and  the  artery  is  expo.sed, 
with  the  vein  behind  it  (after  Zuckerkandl). 


I20 


TREATMENT    OF    HEMORRHAGE. 


Fig-  73-— Exposure  of  the  anterior  and  posterior  tibial  arteries  :  ( i)  Exposure  of  the 
anterior  tibial  artery  of  the  left  leg.  The  fascia  is  opened,  and  the  tibialis  anticus  muscle 
{Ja)  IS  retracted  toward  the  median  line,  and  the  extensor  hallucis  {E.h.)  toward  the 
outer  side.  In  the  interval  between  the  two  muscles  the  deep  peroneal  nerve  (/'./.) 
comes  first  into  view,  and  behind  it  the  artery  surrounded  by  veins. 

(2)  Exposure  of  the  posterior  tibial  artery  behind  the  internal  malleolus.  The  tor- 
tuous artery,  accompanied  by  two  veins,  is  visible  beneath  the  divided  fascia  (F)  (after 
Zuckerkandl).  ^     ^  ^ 


INTERMEDIATE    LIGATION. 


121 


in  the  lumian  subject  in  ligating  large  vessels  in  their  continuity, 
more  especially  if  the  operation  is  done  near  a  large  collateral 
branch,  as  it  approximates  the  inner  surfaces  over  a  larger  area 
and  thus  furnishes  a  more  extensive  surface  for  speedy  cicatri- 
zation. The  experiments  on  the  veins  have  taught  me  another 
important  and  practical  lesson — viz.,  their  tolerance  to  traumatic 
insults  of  all  kinds,  provided  the  seat  of  injury  remains  aseptic. 
In  not  one  of  the  cases  was  death  produced  by  the  operation, 
although  in  a  few  of  the  animals  both  the  jugular  and  femoral 
veins  were  tied  at  different  times.  Progressive  phlebitis,  embolism, 
or  pyemia  was  never  observed.  Like  the  peritoneum,  veins  may 
be  contused,  torn,  lacerated,  cut.  punctured,  burned,  and  ligated 
with  impunity  if  infection  is  avoided.  Veins  are  exceedingly  prone 
to  infection,  but  if  infection  can  be  prevented,  their  injuries  are 
repaired  with  wonderful  rapidity.  As  regards  the  time  required 
for  definitive  obliteration  to  take 
place,  the  results  of  experiments 
would  indicate  that  in  the  case  of 
arteries  of  the  size  of  the  carotid 
or  femoral  from  four  to  seven  days 
are  necessary,  while  in  the  internal  ^^ 

jugular    vein    the    same    object  is 
accomplished  in  three  or  four  days. 


Fig.  74. — Indirect  ligation  of  an  artery  or 
a  vein. 


I''g-  75- — Method  of  controlling  hem- 
orrhage by  ligation  (after  Esmarch)  :  a. 
Artery  ligated  ;   i>,  lateral  ligation  of  vein. 


Intermediate  Ligation — Ligation  en  Masse. — Ambroise  Pare 
and  all  the  older  surgeons  were  in  fear  of  a  too  early  se[jaration 
of  the  ligature,  and  aimed  to  guard  against  secondary  hemoiThage 
as  the  result  of  such  an  occurrence  by  including  adjacent  tissues, 
thus  protecting  the  vessel  against  imdue  j)ressure.  The  object  of 
this  j^ractice  was  simply  to  apply  the  ligature  as  a  provisional  me- 
chanical agent  to  arrest  the  flow  of  blood  in  a  vessel,  without  any 
theory  as  to  the  manner  in  w  hich  permanent  closure  of  the  vessel 
took  place.  The  ligature  was  jjassed  underneath  with  a  needle, 
with  points  of  entrance  and  exit  some  distance  from  the  vessel,  and 
firmly  tied.  This  method  was  originally  practised  by  Pare,  and 
througji  his  influence  and  example  it  was  adoj)ted  by  all  the  [promi- 
nent surgeons  until  neail\'  the  ciid  of  the  eigiiteenth  centurj',  when 


J  22  TREATMENT    OF    HEMORRHAGE. 

Jones  and  his  followers  introduced  the  direct  ligation.  Since  the 
definitive  closure  of  vessels  after  ligation  has  been  made  an  object 
of  study  and  experiment,  this  method  of  ligation  has  been  aban- 
doned, and  is  only  resorted  to  in  exceptional  cases  where  isolation 
of  the  vessel  or  vessels  is  impossible  from  the  nature  or  location  of 
the  wound.  At  the  present  time  we  employ  for  this  purpose  a 
round,  well-curved  needle  armed  with  catgut,  and  frequently  resort 
to  it  in  arresting  hemorrhage  from  scalp  wounds,  meninges,  brain, 
omentum,  mesentery,  and  vessels  near  bones  in  performing  ampu- 
tation. 

Lateral  Ligation. — Since  suturing  of  vessel  wounds  has  become 
a  common  practice  in  appropriate  and  well-selected  cases,  it  has 
almost  entirely  displaced  lateral  ligation,  formerly  frequently  em- 
ployed in  small  wounds  of  large  veins.  The  lateral  ligature  is  not 
to  be  thought  of  in  the  treatment  of  wounds  of  the  arteries,  intra- 
cranial sinuses,  and  large  vein  wounds.  The  only  indication  for 
the  lateral  ligature  is  furnished  by  small  wounds  of  large  veins, 
and  even  in  such  cases  it  is  perhaps  less  safe  than  suturing.  In 
small  vein  wounds  it  usually,  however,  answers  the  purpose  very 
well.  Fine  silk  is  preferable  to  catgut.  The  best  way  to  apply 
the  lateral  ligature  in  such  cases  is  to  pick  up,  with  a  sharp  tenacu- 
lum, both  lips  of  the  wound,  and,  by  making  slight  traction,  make 
a  small  cone  of  the  wounded  side  of  the  vein,  the  base  of  which  is 
then  firmly  tied  with  fine  silk,  which  must  be  made  to  cut  its  way 
deeply  into  the  tissues  to  guard  against  slipping  of  the  ligature. 

Vessel  Suture. — The  arrest  of  hemorrhage  short  of  ligation 
must  be  regarded  as  a  decided  advancement  in  surgery.  The  ligature 
at  once  and  permanently  intercepts  the  circulation,  which  may  lead 
to  gangrene  if  the  wounded  vessel  is  the  principal  artery  at  the  base 
of  an  extremity,  and  the  danger  from  this  source  is  enhanced  if 
the  accompanying  vein  is  involved  in  the  injury  or  is  subjected  to 
ligation,  as  was  advised  by  B.  von  Langenbeck,  Braun,  and  others. 
Niebergall  opposes  Braun 's  advice,  recommending,  in  case  it  be- 
comes necessary  to  ligate  the  common  femoral  vein,  ligation  of 
the  artery  at  the  same  time,  with  a  view  of  reducing  the  danger 
from  gangrene.  He  maintains  that  the  arterial  pressure  in  such 
cases  is  necessary  to  restore  the  collateral  venous  circulation. 
Clinical  experience  adds  weight  to  this  opinion.  In  twenty-five 
cases  in  which  the  femoral  vein  was  ligated  alone,  gangrene  did  not 
follow  once.  •  Simultaneous  ligation  of  both  vessels  in  twenty-four 
cases  resulted  in  gangrene  fourteen  times.  Suturing  of  vessel  wounds 
should  take  the  place  of  the  ligature  only  in  case  the  size  of  the  ves- 
sel is  such  that  the  sudden  arrest  of  circulation  would  cause  gangrene 
of  a  limb  or  of  some  important  organ — as,  for  instance,  when  the 
vessel  wound  involves  the  carotid  artery,  internal  jugular  vein,  or 
the  subclavian,  axillary,  and  femoral  arteries  and  veins. 

Suturing  is  only  applicable  to  comparatively  small  wounds,  for 
when  the  wound  is  large,  the  narrowing  of  the  lumen  of  the  vessel 


SUTURE    OF    ARTERIES.  I  23 

by  suturing  would  be  almost  equivalent  to  ligation,  with  the  prob- 
ability that  the  obstruction  would  soon  become  complete  by  the 
subsequent  formation  of  a  thrombus.  In  all  vessel  wounds  where 
no  serious  consequences  are  likely  to  follow  the  sudden  interruption 
of  circulation,  the  ligature  is  indicated.  The  experiments  of  Gluck 
made  upon  animals  for  the  purpose  of  demonstrating  the  value  of 
vessel  suture  have  }^ielded  practical  results.  He  has  shown  that 
vein  wounds  will  heal  promptly  after  suturing  or  closure  by  means 
of  aluminum  clamps,  without  obliteration  of  the  lumen  of  the 
vessel.  He  places  great  stress  on  the  importance  of  bringing 
the  intima  in  accurate  and  uninterrupted  contact.  In  his  valu- 
able monograph  on  this  subject  he  refers  to  the  cases  of  vein 
wounds  treated  by  suturing  b}'  Billroth,  Schede,  and  others,  and 
the  cases  of  successful  suturing  of  arterial  wounds  by  Israel 
(common  iliac)  and  Zoege-Manteufifel  (femoral  arter\-). 

Suture  of  Arteries. — A  few  years  ago  suture  of  arterial  wounds 
was  not  thought  of,  as  success  was  deemed  be\-ond  the  realm  of 
possibilit}-.  The  intravascular  pressure  and  the  constant  motion 
caused  by  the  arterial  waves  were  considered  incompatible  with  the 
healing  of  such  a  wound.  Another  great  objection  was  the  well- 
founded  fear  of  the  formation  of  a  thrombus  at  the  seat  of  injury  ; 
and  e\'en  if  such  a  feat  had  been  considered  possible,  it  was 
expected  that  the  scar  would  later  yield  and  furnish  the  starting- 
point  of  an  aneurwsm.  Although  a  few  apparently  well-authenti- 
cated cases  of  successful  suturing  of  arterial  wounds  have  been 
reported,  we  can  not  say  at  the  present  time  that  the  latter  objec- 
tions have  no  foundation.  Collateral  circulation  is  sometimes 
established  so  rapidh'  that  it  is  not  always  possible  to  determine 
from  the  condition  of  the  peripheral  pulse  whether  or  not  the  lumen 
of  the  vessel  at  the  seat  of  injuiy  remained  patent  without  direct 
evidence  furnished  by  examination  of  the  specimen.  All  the 
alleged  successful  ca.ses  of  this  kind  are  of  comparative!}'  recent 
date,  and  we  have  not  sufficient  proof  of  the  reliabilit\'  of  the  scar 
in  guarding  against  a  remote  traumatic  aneurysm.  Additional 
experimental  researches  and  a  larger  clinical  material  are  necessary 
to  establish  arterial  suture  as  a  reliable  hemostatic  resource. 

There  can  be  but  little  doubt,  however,  that  it  will  secure  for 
itself  a  permanent  place  in  surgery  in  the  treatment  of  small  wounds 
of  large  arteries,  where  for  good  reasons  the  consequences  of  liga- 
tion are  feared.  The  late  Heidenhain  was  instrumental  in  bringing 
this  subject  prominently  before  the  profession.  In  the  removal  of 
the  a.xillar}'  contents  for  malignant  disease,  a  longitudinal  wound  in 
the  axillary  artery  was  made  by  his  assistant,  who  used  the  scissors 
too  freely.  The  edges  of  the  wound  were  picked  up  with  dissect- 
ing forceps,  and  the  opening  was  clo.sed  with  fine  catgut  sutures 
in.scrted  with  a  round  intestinal  needle.  In  tying  the  sutures  the 
lumen  of  the  vessel  was  only  slightly  narrowed.  A  section  of  the 
axillary  vein  was  intentionally  excised,  owing  to  the  extent  of  the 


124  TREATMENT    OF    HEMORRHAGE. 

disease.  The  pulsations  of  the  artery  continued,  and  six  months 
later  the  patient  was  in  excellent  condition.  Heidenhain  does  not 
approve  of  inverting  the  margins  of  the  wound  and  sewing  only 
the  adventitia  and  media,  as  has  been  recommended  by  others,  but 
he  advocates  bringing  the  endothelial  surfaces  in  contact  by 
approximating  the  intima.  He  includes  in  the  sutures  all  the 
vessel  tunics.  Villar  and  Branchet  exclude  the  blood  from  the 
injured  portion  of  the  vessel  by  digital  compression,  and  make  use 
of  a  second  row  of  sutures,  which  include  the  sheath  of  the  vessel 
and  the  overlying  adipose  tissue.  These  authors,  as  well  as  von 
Horoch,  Jassikowski,  and  Burci,  use  fine  silk,  a  round  needle,  and 
include  in  the  first  row  of  sutures  only  the  adventitia  and  media. 
Israel  doubts  the  propriety  of  suturing  arterial  wounds  when  the 
vessels  are  atheromatous,  but  Heidenhain  claims  that  this  pathologic 
condition  does  not  furnish  a  contraindication  to  suturing.  Two 
cases  of  arterial  suturing  are  reported  by  Durante.  In  one  case 
the  injured  vessel  was  the  posterior  tibial  artery,  in  the  other,  the 
axillary.  Stafanjew  sutured  a  wound  of  the  femoral  by  using 
four  sutures,  which  included  only  the  adventitia.  Three  months 
later  the  lumen  of  the  vessel  appeared  to  be  patent.  In  another 
case  he  incised  the  femoral  artery  for  the  removal  of  an  embolus  in 
a  case  of  endocarditis.  The  wound  was  sutured  in  a  similar  man- 
ner. Nineteen  days  later  the  patient  died,  and  examination  of  the 
sutured  vessel  showed  that  the  lumen  was  open  at  the  point  of 
suturing  and  the  vessel  wound  healed.  It  seems  to  me  that  in 
closing  an  arterial  wound  by  suturing  the  example  of  Heidenhain 
deserves  special  consideration,  as  his  method  of  closing  the  wound 
brings  each  one  of  the  vessel  tunics  in  contact  and  places  the  tis- 
sues in  a  condition  for  an  ideal  repair,  leaving  at  the  same  time  the 
inner  surface  of  the  wound  in  a  condition  least  likely  to  be  followed 
by  thrombosis. 

Fine  catgut  is  the  best  material  for  vessel  suture,  as  it  leaves 
no  foreign  substance  either  in  the  lumen  or  in  the  wall  of  the  ves- 
sel beyond  the  time  necessary  for  the  presence  of  an  adequate 
mechanical  support.  An  additional  row  of  sutures,  as  recommended 
by  Villar  and  Branchet,  adds  to  the  strength  of  the  wounded  arte- 
rial wall,  and  is  an  additional  safeguard  against  hemorrhage  and 
aneurysmal  dilatation.  Longitudinal  wounds  are  better  adapted 
for  treatment  by  suturing  than  transverse  wounds.  If,  in  the  latter 
case,  the  wound  involves  more  than  one-third  of  the  circumference 
of  the  artery,  an  attempt  at  suturing  must  be  regarded  as  a  ques- 
tionable procedure.  Suturing  is  only  applicable  to  incised  wounds. 
Gunshot  and  lacerated  wounds  must  be  treated  by  ligation  regard- 
less of  their  location  and  size. 

Suture  of  Veins. — Suture  of  veins  has  a  much  wider  field  of 
usefulness  than  artery  suture,  owing  to  the  slight  or  negative  intra- 
vascular pressure.  The  larger  the  wounded  vein,  the  more  urgent 
are  the  indications  for  the  use  of  the  suture  in  place  of  the  ligature. 


SUTURE    OF    VEINS.  I  25 

A  sufficient  number  of  well-authenticated  cases  of  successful  vein 
suture  are  now  on  record  to  prove  that  lateral  wounds  can  be  sutured 
and  will  heal  without  obliteration  of  the  lumen  of  the  vessel  by- 
thrombus  formation.  Tichow  made  thirty  experiments  on  sixteen 
dogs.  He  made  longitudinal  and  transverse  wounds,  and  in  some 
of  the  experiments  cut  away  a  part  of  the  vein-wall.  The  wounded 
portion  of  the  vein  was  made  bloodless  by  placing  a  silk  ligature 
above  and  below  the  wound.  The  ligature  was  drawn  sufficiently 
tight  around  the  vein,  and  the  ends  were  crossed,  but  not  tied,  and 
held  with  hemostatic  forceps.  As  suture  material  he  gives  the  finest 
silk  the  preference  over  catgut.  In  two  cases  in  which  catgut  was 
used  secondary  hemorrhage  occurred,  while  this  mishap  never  took 
place  in  wounds  sutured  with  silk.  He  usually  made  use  of  the 
continuous  suture,  and  if,  on  removal  of  the  ligatures,  hemorrhage 
occurred  at  a  point,  an  additional  suture  was  inserted  and  tied. 
Like  Schede,  he  does  not  consider  approximation  of  the  intima  as 
essential  to  success.  In  transverse  wounds  it  is  necessary  to  place 
the  sutures  closer  together  than  in  longitudinal  wounds.  Suppura- 
tion appeared  to  inflict  no  damage  on  the  vein  or  interfere  with  the 
healing  of  the  wound.  This  immunit}^  to  septic  intravenous  com- 
plications in  suppuration  at  the  seat  of  suturing  is  probably  more 
marked  in  dogs  than  in  the  human  subject.  Specimens  were  exam- 
ined in  from  one  to  thirty-three  days  after  the  operation.  In  thirty 
cases  thrombosis  occurred  eight  times.  In  the  course  of  time  the 
sutures  were  always  found  in  the  perivascular  scar  ;  they  never 
traveled  in  the  direction  of  the  lumen  of  the  vessel.  During  the 
healing  process  a  small  mural  thrombus  was  always  formed  over 
the  inner  surface  of  the  wound.  Wounds  of  nearly  all  the  larger 
veins  have  been  successfully  sutured. 

Nicaise  successfully  treated  a  wound  of  the  innominate  vein  by 
this  method  a  number  of  years  ago.  While  removing  a  large 
fibrosarcoma  of  the  thyroid  gland  he  cut  the  internal  jugular  vein 
at  its  junction  with  the  subclavian.  As  it  was  found  impossible  to 
apply  a  ligature  that  would  have  arrested  the  hemorrhage,  he 
closed  the  wound  by  means  of  Lembert  sutures,  with  a  permanently 
successful  result.  Schwyzer  recently  sutured  a  lateral  wound  of 
the  superior  and  inferior  mesenteric  vein,  cut  during  an  operation 
for  the  removal  of  a  malignant  tumor  of  the  transverse  colon, 
which,  owing  to  its  extension  to  adjacent  organs,  necessitated  par- 
tial excision  of  the  stomach  and  pancreas,  besides  an  extensive 
colectomy.      His  patient  made  a  speedy  and  uneventful  recovery. 

In  suturing  a  vein  wound  it  is  necessary  to  render  the  wounded 
part  of  the  vessel  bloodless  In'  the  use  of  two  temporary  ligatures, 
which  are  applied  only  with  sufficient  firmness  to  interrupt  the 
circulation.  The  constriction  is  best  effected  by  the  use  of  hemo- 
static forceps  instead  of  tying,  as  has  been  suggested  by  Tichow. 
Fine  catgut  would  appear  to  be  as  serviceable  as  silk,  and,  as 
an    additional    safeguard,    a   second    row   of   paravascular   sutures 


126  TREATMENT    OF    HEMORRHAGE. 

might  be  employed.  The  strictest  aseptic  precautions  must  be 
resorted  to,  for  the  purpose  of  guarding  against  septic  thrombo- 
phlebitis and  its  disastrous  immediate  and  late  consequences. 

Sinus  Suture. — Of  the  intracranial  sinuses,  the  superior  longi- 
tudinal sinus  is  the  only  one  that  occasionally  can  be  sutured  suc- 
cessfully when  the  wound  is  not  too  large  and  the  cranial  defect  is 
sufficiently  extensive  to  render  the  wound  accessible  for  suturing. 
Wounds  of  the  remaining  sinuses  are  best  treated  by  antiseptic 
tamponade  or  implantation  of  a  fragment  of  aseptic  sponge.  In 
my  experiments  on  animals  I  found  it  extremely  difficult  to  suture 
transverse  wounds  of  the  superior  longitudinal  sinus,  and  my  ex- 
perience led  me  to  the  conclusion  that  arrest  of  hemorrhage  by 
suturing  in  such  cases  is  only  possible  in  case  the  wound  is 
small.  The  difficulty  in  closing  transverse  wounds  consists  in  ap- 
proximating the  margins.  The  margins  of  the  wound  retract,  the 
opening  of  the  sinus  assumes  a  diamond  shape,  and  the  sutures  are 
liable  to  tear  through  the  tissues  on  tying  them.  This  is  what 
happened  in  one  experiment.  The  longitudinal  sinus  in  a  horse 
was  cut  transversely  for  the  purpose  of  studying  the  conditions 
that  determined  air  embolism.  The  wound  margin  retracted  at 
once,  converting  the  transverse  incision  into  a  diamond-shaped 
opening.  After  the  necessary  information  had  been  obtained,  an 
effort  was  made  to  close  the  wound  by  suturing.  "  Three  catgut 
sutures  were  passed  through  both  edges  of  the  wound,  but  on 
attempting  to  approximate  its  margins,  every  one  of  them  tore 
through  the  tissues  before  the  parts  were  in  apposition,  proving 
conclusively  that  large  transverse  wounds  of  the  longitudinal  sinus 
can  not  be  sutured,  owing  to  the  nature  of  the  tissues  and  the  in- 
trinsic tendency  to  marked  retraction." 

In  suturing  longitudinal  wounds  of  this  sinus  the  conditions  are 
more  favorable  :  there  is  less  retraction,  and  the  margins  of  the 
wound  can  be  brought  and  held  in  contact  by  sutures.  In  such 
cases  it  is,  however,  preferable  to  use  fine  silk  in  place  of  catgut,  as 
the  wall  of  the  sinus  is  thicker  and  firmer  than  the  vein  coats,  and 
more  force  must  be  overcome  in  closing  the  wound.  A  small, 
round,  sharply  curved  needle  must  be  selected  for  the  insertion  of 
the  sutures,  as  the  cranial  defect  through  which  the  operation  must 
be  performed  is  usually  a  limited  one.  The  sutures  should  include 
all  the  tissues  with  the  exception  of  the  intima. 

Arterial  Invagination. — Attempts  have  been  made  to  substi- 
tute arterial  invagination  for  the  ligature  in  wounds  of  large  arteries 
not  amenable  to  successful  treatment  by  suturing.  Dr.  J.  B.  Mur- 
phy has  made  a  series  of  very  interesting  experiments  to  demon- 
strate the  feasibility  and  safety  of  such  a  procedure,  and  the  results 
have  been  such  as  to  justify  further  research.  He  invaginates  the 
proximal  into  the  distal  end,  and  secures  the  invagination  by  from 
four  to  six  fine  catgut  sutures.  In  many  of  the  experiments 
the   lumen   of  the  vessel   became   occluded   by  thrombus  forma- 


TORSION. 


127 


Fig.  76. 


-Method  of  suturing  a  blood-vessel  by 
invagination  (Murphy). 


tion.  while  in  some  the  experiment  appears  to  have  proved  suc- 
cessful. In  two  cases  of  stab  wounds  of  the  femoral  artery  the 
same  surgeon  performed  arterial  invagination  with  success.  Whether 
or  not  in  these  cases  the 
lumen  of  the  vessel  re- 
mained patent,  or  whether 
the  \igorous  peripheral  cir- 
culation followed  in  conse- 
quence of  the  development 
of  a  speed)-  and  efficient  col- 
lateral circulation,  it  would 
be  difficult  to  prove.  The 
idea  is  an  excellent  one,  and 
the  subject  deserves  further 
experimentation  and  inves- 
tigation. With  the  infor- 
mation at  hand  at  this  time,  few  surgeons  would  have  the  courage 
to  substitute  invagination  for  the  ligature  in  the  treatment  of 
wounds  of  arteries  of  the  size  of  the  axillary  or  femoral. 

Torsion. — The  arrest  of  hemorrhage  by  torsion  (hig.  J"]^,  once 
so  popular,  has  given  wa}'  largely  to  the  use  of  the  modern  aseptic 
ligature.  Wliere\  er  and  whenever  a  ligature  can  be  applied,  tor- 
sion is  no  longer  practi.sed  except  for  arresting  bleeding  from  small 
vessels  in  case  it  is  deemed  objectionable  to  make  use  of  numerous 
ligatures — as,  for  instance,  in  performing  plastic  operations.  Tor- 
sion arrests  hemorrhage  by  tearing  the  tunics  of  the  end  of  the 
bleeding  vessel  if  the  vessel  is  large,  or  by  twisting  the  surrounding 
tissues  around  the  bleeding  point  if  the  vessel  is  small. 

In  performing  torsion  of  a  large  vessel  the  end  should  be 
isolated  for  half  an  inch  at  least,  the  isolated  portion  grasped 
transversely  with  a  pair  of  hemostatic  forceps,  and  the  projecting 
end  grasped  in  its  long  axis  with  another  forceps,  which  is  then 

twisted  around  its  axis  until  the 
tissues  are  torn  sufficiently  to 
form  a  mass  of  shreds,  strong 
and  intricate  enough  to  act  as 
a  substitute  for  the  ligature.  If 
a  vessel  can  be  thus  treated,  it 
is  certainly  sufficiently  accessi- 
ble to  apply  a  ligature,  and  there 
seems  to  be  no  excuse  to  rely 
on  it  as  a  i)ermanent  hemostatic 
resource  except  in  the  absence 
of  reliable  ligature  material. 
Torsi(^n  of  small  vessels  can  only  be  practised  effectually  if  the 
vessel  is  embedded  in  firm  connective  tissue  ;  it  is  Vv^or.sc  than  u.se- 
less  in  attempts  to  arrest  hemorrhage  from  fragile  vascular  organs, 
such   as   the    .sijleen,    liver,   and    kidneys.      The   bleeding   point   is 


-Proper    method    of   j)crforniing 
torsion. 


I30 


TREATMENT    OF    HEMORRHAGE. 


Hamilton  recommended  water  heated  to  near  the  boihng-point,  and 
did  not  observe  any  retarding  influence  from  its  use  on  the  heahng  of 
wounds.  John  Hunter  advised  a  temperature  at  which  the  hand 
could  be  immersed  without  great  discomfort.  This  direction  in 
determining  the  hemostatic  temperature  of  water  can  be  relied  upon 
as  safe  in  practice.  The  immediate  effect  of  the  action  of  water  at  this 
temperature  is  to  contract  the  bleeding  blood-vessels  and,  at  the  same 
time,  form  a  thin  film  of  coagulated  albumin  on  the  surface  of  the 
wound,  upon  which  the  hemostatic  action  largely  depends.  In 
place  of  plain  water  it  is  better  to  use  a  hot  normal  salt  solution, 
as  the  hemostatic  effect  is  the  same  and  the  saline  solution  has  a 
more  beneficial  effect  on  the  tissues  than  plain  sterilized  water.  Hot 
saline  solution  has  a  wide  field  of  usefulness  in  arresting  parenchy- 
matous oozing,  and  its  use  rather  expedites  than  retards  ideal  heal- 
ing of  the  wound.  The  hemostatic  effect  is  increased  by  pouring 
the  hot  solution  in  a  large  stream  from  a  pitcher  at  some  height 
over  the  surface  of  the  wound.  The  use  of  the  hot  solution  of  salt 
is  frequently  combined  with  surface  compression,  in  which  case  the 
gauze  compress  is  saturated  with  the  solution  heated  to  the  requisite 
hemostatic  temperature. 

Steam. — Steam  has  recently  been  used  to  some  extent  as  a  sub- 
stitute for  hot  water  as  a  hemostatic  agent.  It  is  not  probable  that 
it  will  take  the  place  of  hot  water  to  any  considerable  extent  for 
this  purpose.  A  tea-kettle  is  as  good  a  utensil  as  any  in  making 
use  of  this  form  of  heat,  as  the  escaping  steam  from  the  spout  can 
be  applied  to  the  bleeding  surface  without  doing  any  damage  to 
parts  that  should  be  avoided.  It  is  of  special  utility  in  arresting 
troublesome  parenchymatous  oozing.  Its  application  should  be 
continued  until  a  thin  film  of  coagulated  albumin  covers  the  surface. 

Snegirew  has  used  steam  for  a  number  of  years  as  a  hemostatic, 
more  especially  in  operations  upon  the  uterus.  He  uses  it  in  the 
following  manner :  After  the  uterus  has  been  dilated,  a  fenestrated 
catheter  is  inserted  into  the  cavity.  In  the  lumen  of  the  instrument 
passes  a  smaller  tube  which  is  connected  with  a  steam  generator. 
The  steam  has  a  temperature  of  212°  F.  After  the  steam  has  been 
applied  for  from  one-half  to  one  minute,  its  caustic  and  hemostatic 
action  begins,  and  the  surface  of  the  wound  is  covered  with  a  thin 
layer  of  coagulated  albumin.  The  action  of  the  steam  is  almost 
painless.  He  first  tested  the  hemostatic  properties  of  steam  on  the 
lower  animals,  and  the  results  obtained  led  him  to  an  extensive  use 
of  it  in  his  operative  work.  Jaworski  fully  corroborates  the  views 
of  Snegirew.  He  removed  portions  of  the  liver,  kidney,  lungs,  and 
uterus  in  animals,  relying  on  hot  steam  exclusively  in  arresting  the 
profuse  hemorrhage  from  these  vascular  organs,  with  the  result  that 
very  little  blood  was  lost.  He  has  made  use  of  it  in  his  practice  in 
resection  of  the  knee-joint,  excision  of  the  mammary  gland  for  car- 
cinoma, removal  of  different  kinds  of  tumors  in  other  localities,  and 
operations  on  the  uterus,  with  the  most  gratifying  results. 


ASEPTIC    TAMPONADE.  I3I 

Cold. — Cold  in  any  form  has  the  same  effect  on  the  blood- 
vessels as  its  counterpart,  heat — that  is,  it  produces  contraction  of 
the  blood-vessels,  to  which  action  its  hemostatic  properties  must  be 
attributed.  As  it  does  not  coagulate  albumin,  its  power  of  arrest- 
ing hemorrhage  is  inferior  to  that  of  heat.  Cold  enjoyed  an  envi- 
able reputation  as  a  hemostatic  among  surgeons  and  the  laity  for  a 
long  time,  but  tiie  indications  for  its  employment  at  the  present  time 
are  quite  limited.  It  is  absolutely  contraindicated  in  cases  of  hem- 
orrhage complicated  by  shock,  and  it  should  not  be  used  after  acute 
anemia  has  occurred,  as  its  extensive  and  prolonged  use  might 
counteract  prompt  reaction  after  the  hemorrhage  has  been  arrested. 
The  emplo}'ment  of  cold  in  arresting  hemorrhage  is  indicated  in 
plethoric  persons  with  an  unimpaired  heart  muscle  ;  also  in  cases 
of  hemorrhage  from  inflamed  surfaces  if  it  is  deemed  advisable  to 
arrest  the  bleeding.  Cold  is  employed  in  the  form  of  ice,  cold 
water,  and  spray.  Ethyl  chlorid  spray  has  been  used  with  bene- 
fit in  arresting  obstinate  hemorrhage  after  extraction  of  teeth.  After 
cleaning  out  the  blood-clot,  the  cavity  is  frozen,  and  later  packed 
with  a  10  per  cent,  solution  of  antipyrin  (Da  Costa)  or  tincture  of 
hamamelis  (A.  E.  Hind). 

Acupressure. — Simpson's  method  of  arresting  hemorrhage  by 
acupressure,  once  so  popular,  has  for  good  reasons  become  almost, 
if  not  entirely,  obsolete.  Wherever  the  acupressure  needle  can  be 
applied  efficiently  the  hemorrhage  can  be  arrested  by  the  direct  or 
indirect  ligature  or  by  aseptic  tamponade. 

Aseptic  Tamponade. — Aseptic  tamponade  arrests  hemorrhage 
b\'  uninterrupted  surface  compression  with  an  aseptic  tampon  which 
remains  /;/  situ  until  the 
bleeding  vessels  have  be- 
come obliterated  at  the 
point  of  compression  by 
thrombosis  and  intravas- 
cular   cicatrization    (Figs. 

80  and  81).     The  aseptic       T?Qn-  .•    . 

'  .  '  rig.  00. — Conic  aseptic  tampon  compressing  an 

tampon  has  a  wide  range  artery. 

of  usefulness   in   arresting 

troublesome  surface  bleeding,  and  occasionally  is  relied  upon  in 
arresting  hemorrhage  from  ves.sels  of  considerable  size  when  the 
vessel  wound  is  not  accessible,  or  can  not  readily  be  made  so,  to 
more  direct  measures.  Wounds  of  any  of  the  intracranial  sinuses 
that  can  not  be  sutured  should  be  tamponed  with  a  stri[)  of  iodo- 
form gauze,  which  is  left  in  the  wound  for  three  or  four  days,  by 
which  timi;  the  sinus  on  each  side  of  the  tampon  will  be  foimd 
permanently  obliterated  by  a  firm  thrombosis,  reiulering  the  further 
use  of  the  tampon  unnecessary.  If  only  a  small  tampon  is  re- 
quired, iodoform  gauze  should  be  used ;  if  a  large  tampon  is 
refjuircd,  especially  in  the  case  of  children,  the  aged,  and  in  persons 
the  subjects  of  renal  disease,  iod(jform  gauze  is  used  sparingly,  and 


132 


TREATMENT    OF    HEMORRHAGE. 


the  bulk  of  the  tampon  is  made  up  of  sterile  gauze,  as _  a  large 
iodoform  gauze  tampon  might  lead  to  grave,  if  not  fatal,  intoxica- 
tion. The  Mikulicz  tampon  is  the  ideal  one  if  the  bleeding  space 
is  large,  as  is  often  the  case  in  abdominal  and  pelvic  operations. 
It  consists  of  a  mantle  or  pouch  of  iodoform  gauze,  to  the  center 

of  which  is  tied  a  silk  ligature  to  facili- 
.■■'^^  tate  its  removal.     The  interior  of  the 

pouch  is  packed  with  strips  of  sterile 
gauze  until  the  necessary  degree  of 
pressure  is  secured.  The  silk  ligature 
is  brought  out  over  the  packing,  and 
the  pouch  is  tied  with  a  strip  of  gauze. 
When  the  tampon  is  removed,  the 
pieces  of  gauze  are  extracted,  the  silk 
ligature  secured,  and  when  the  pouch 
is  empty,  it  is  removed  by  making  trac- 
tion on  the  silk  ligature.  In  using  the 
tampon  in  this  manner  there  is  no 
danger  of  leaving  pieces  of  gauze  in 
the  wound.  If  the  ordinary  tampon  is 
used,  it  is  made  of  one  piece  of  gauze, 
to  guard  against  forgetting  or  over- 
looking a  piece  of  gauze  in  the  wound. 
If  the  tampon  is  used  to  control  hem- 
orrhage from  a  vessel  of  considerable 
size,  it  is  made  in  the  shape  of  a  gradu- 
ated compress,  the  apex  resting  against 
the  point  where  pressure  is  needed — 
that  is,  the  bleeding  vessel.  Under 
such  circumstances  the  aseptic  tampon 
not  only  serves  the  useful  purpose  of 
a  hemostatic,  but,  at  the  same  time,  acts  as  an  efficient  capillary 
drain. 

Wound  Suture. — The  buried  absorbable  aseptic  suture  is  not 
infrequently  relied  upon  as  a  hemostatic  in  arresting  parenchy- 
matous hemorrhage.  It  takes  the  place  of  the  indirect  ligature 
in  controlling  hemorrhage  from  bleeding  points,  and,  by  coaptating 
the  wound  surfaces,  furnishes  the  most  favorable  condition  for  the 
formation  of  minute  thrombi  which  arrest  the  hemorrhage  by  oc- 
cluding the  cut  ends  of  the  bleeding  vessels.  According  to  the 
depth  of  the  wound,  from  one  to  several  rows  of  sutures  are  made. 
Suturing  for  such  an  indication  must  be  done  with  a  round,  curved 
needle  and  fine  catgut.  Points  that  bleed  freely  should  be  included 
in  the  sutures.  Accurate  coaptation  of  the  wound  surfaces  secured 
by  this  method  of  suturing  will  usually  obviate  the  necessity  for 
drainage,  as  the  formation  of  dead  spaces  is  prevented  and  the 
parts  are  placed  in  an  ideal  condition  for  speedy  union  by  primary 
intention. 


Fig.  8l. — Wound  of  deep 
palmar  arch  treated  by  aseptic 
tamponade  ;  dressing  complete. 


STYPTICS.  I  3  3 

Electricity. — The  profuse  capillary  hemorrhage  which  so  often 
follows  the  removal  of  the  elastic  constrictor,  used  either  for  pro- 
phylactic or  therapeutic  purposes,  constitutes  one  of  the  disadvan- 
tages of  the  bloodless  method  of  operating.  Riedinger  attributes 
this  often  troublesome  sequela  of  elastic  constriction  to  temporary 
muscular  paralysis.  He  has  found  the  use  of  electricity  the  most 
reliable  means  in  limiting  the  parenchymatous  oozing.  After  the 
operation  is  completed  all  visible  vessels  are  ligated.  A  large 
aseptic  sponge,  connected  with  the  electrode  of  a  strong  induction 
apparatus,  is  placed  over  the  surface  of  the  wound,  while  a  second 
sponge,  connected  with  the  other  electrode,  is  held  on  the  side  of 
the  wound,  and  for  a  minute  the  current  is  employed,  when  the 
elastic  constrictor  is  removed.  In  this  manner  the  capillary  hem- 
orrhage is  reduced  to  a  minimum. 

Styptics. — The  modern  technic  of  hemostasis  has  fortunately 
limited  the  use  of  styptics  to  exceptional  cases.  The  styptics  in 
such  common  use  in  the  past — astringent  preparations  of  iron, 
alum,  tannin,  and  other  vegetable  astringents — are  incompatible 
with  a  speedy  and  ideal  wound  healing,  and  should  be  avoided 
whenever  arrest  of  hemorrhage  is  possible  with  agencies  less  dis- 
turbing to  the  process  of  repair.  All  styptics  are  more  effective 
when  applied  to  the  bleeding  surface  on  a  pledget  of  gauze  or 
cotton  and  combined  with  pressure.  All  styptics  owe  their  hemo- 
static properties  to  their  power  of  coagulating  albuminoid  sub- 
stances, including  the  formation  of  an  intravascular  thrombus  in 
the  cut  ends  of  the  bleeding  vessel.  One  of  the  best  styptic  appli- 
cations is  the  old-fashioned  adhesive  resin  gauze  of  Lister,  in  the 
meshes  of  which  has  been  rubbed  finely  powdered  tannin.  This 
styptic  application  was  in  great  favor  with  Billroth.  Instead  of 
the  tannin  the  salt  of  persulphate  of  iron  or  powdered  alum  can  be 
used.  The  styptic  solutions  of  iron  preparations,  the  tincture  of 
muriate  of  iron,  and  the  solution  of  persulphate  of  iron  (liquor  ferri 
persulphatis)  remain  popular  st}'ptics  with  the  profession. 

Oil  of  turpentine  is  an  old  and  a  reliable  local  hemostatic  in 
many  cases  of  troublesome  hemorrhage  from  a  limited  surface,  as 
after  excision  of  the  tonsils.  Saese  has  used  it  with  success  in 
arresting  hemorrhage  after  tooth  extraction,  by  tamponing  the 
cavity  with  cotton  saturated  with  turpentine.  He  has  also  employed 
it  with  benefit  internally  in  emulsion  in  doses  of  five  drops  every 
hour  in  hemorrhage  from  the  kidneys  and  bladder. 

Ferripyrin  is  a  combination  of  chlorid  of  iron  and  antipyrin, 
and  has  been  used  with  success  in  20  per  cent,  solution  in  the  clinic 
of  Jurasz  in  arresting  troublesome  cpistaxis.  A  pledget  of  cotton 
is  saturated  with  the  solution  or  sprinkled  with  the  powder  and  is 
applied  to  the  bleeding  surface.  This  preparation  does  not  cauter- 
ize, and  acts  at  the  same  time  as  a  mild  local  anesthetic.  Froh- 
mann  has  u.sed  the  same  hemostatic  in  arresting  hemorrhage  in 
more  than   one   hundred   cases  of  tooth   extraction,  with  the  most 


134 


TREATMENT    OF    HEMORRHAGE. 


gratifying  results.  Schaeffer  has  recommended  ferripyrin  in  gyne- 
cologic and  obstetric  practice  as  an  efficient  and  reliable  hemostatic. 

Antipyrin  has  been  shown  by  the  experiments  of  Park  on  ani- 
mals to  possess  valuable  hemostatic  properties.  It  was  found  that 
it  is  at  the  same  time  a  decided  antiseptic.  He  recommends  a  5  per 
cent,  solution  to  be  used  in  the  form  of  a  spray  by  compress  or  by 
injection.  It  has  been  employed  in  the  treatment  of  free  surface 
bleeding,  and  recommends  itself  more  especially  in  the  treatment  of 
obstinate  epistaxis. 

Hemorrhage  from  Bone. — Troublesome  hemorrhage  from  bone 
must  be  met  by  special  remedial  agents,  as  ligation  and  most  of 
the  other  hemostatic  resources  referred  to  are  inapplicable  in  such 
cases.  Bleeding  from  bone  in  craniectomy,  necrotomy,  resection, 
and  amputation  from  vessels  of  considerable  size  is  often  encoun- 
tered and  frequently  proves  obstinate.  The  middle  meningeal 
artery  is  occasionally  found  in  a  complete  bony  canal,  and  when 
injured,  the  bleeding  can  be  arrested  by  crushing  the  bone  around 
the  bleeding  point  with  strong  forceps  or  by  spiking  the  canal  with 
an  aseptic  bone  or  ivory  nail.  Should  such  nails  not  be  at  hand,  a 
sterilized  toothpick  or  match  can  be  used  for  the  same  purpose.  As 
wood  is  not  absorbable,  the  nail  must  be  left  long  enough  to  facili- 
tate its  subsequent  removal.  Rapin  resorted  to  ordinary  shoe-pegs 
in  arresting  hemorrhage  from  bone  in  a  case  of  resection  of  the  rec- 
tum by  Kraske's  method.  From  the  resected  surface  of  the  sacrum 
the  bleeding  was  promptly  arrested  by  driving  aseptic  pegs  into  the 
bone  at  points  from  which  the  bleeding  was  profuse.  From  one  to 
six  nails  usually  suffice  in  such  cases.  The  nails  are  extracted 
after  the  completion  of  the  operation,  but  if  the  hemorrhage  re- 
turns, they  are  again  employed  in  the  same  manner.  Riedinger 
employed  the  catgut  tampon  in  a  case  of  troublesome  hemorrhage 
from  the  tibia  after  amputation  of  the  leg.  An  artery  of  consider- 
able size  in  the  dense  compacta  was  the  source  of  the  bleeding. 
The  lumen  of  the  vessel  was  tamponed  with  pieces  of  catgut  that 
were  inserted  parallel  to  each  other,  until  the  space  was  plugged 
sufficiently  to  arrest  the  hemorrhage.  The  use  of  such  an  absorb- 
able tampon  recommends  itself  very  highly  in  arresting  hemorrhage 
from  large  vascular  spaces  in  the  cut  surface  of  the  bone.  The 
needle  point  of  the  Paquelin  cautery  at  a  dull  heat  is  an  important 
hemostatic  resource  in  arresting  hemorrhage  from  bone.  The 
eschar  created  does  not  interfere  with  a  satisfactory  healing  of  the 
wound.  If  the  bleeding  is  from  small  vessels  in  the  spongy  struc- 
ture of  the  bone,  compression  of  the  spongiosa  by  striking  it  with 
a  metallic  hammer,  forceps,  or  blunt  end  of  a  chisel  will  usually 
succeed  in  arresting  the  parenchymatous  bleeding. 

General  Treatment. — Very  little  can  be  expected  from  general 
treatment  until  the  hemorrhage  is  arrested  by  local  measures.  The 
administration  of  stimulants  of  any  kind  is  absolutely  contraindicated 
until  the  hemorrhage  is  under  control.     Any  treatment  calculated  to 


GENERAL    TREATMENT.  I35 

increase  the  licarf  s  action  and  to  intensify  the  intravascular  pressure 
must  be  carefully  avoided  as  a  source  of  danger  by  aggravating  the 
hemorrhage  atid  by  antagonizvig  nature''  s  resources  in  effecting  spon- 
taneous arrest  of  hemorrhage.  In  some  instances  where  the  source 
of  hemorrhage  can  not  be  reached,  it  would  appear  rational  to 
pursue  an  opposite  course  and  diminish  intrav^ascular  tension  and 
the  force  of  the  heart  muscle  by  a  timely  resort  to  the  use  of  the 
lancet.  Stimulation  is  in  place  and  urgently  called  for  xvhen  the  patient 
is  much  prostrated  frojn  the  loss  of  blood,  and  further  bleeding  has  been 
guarded  against  by  effective  Jienwstasis.  In  such  cases  the  use  of 
hot  wine,  or  the  more  concentrated  alcoholic  stimulants,  given  in 
decided  doses  at  short  intervals,  is  best  calculated  to  establish  speedy 
and  satisfactory  reaction.  The  body-heat  must  be  carefully  pre- 
served in  such  cases  by  the  use  of  dry  heat  applied  to  the  extremi- 
ties, and  in  grave  cases,  to  the  entire  length  of  the  trunk.  If  the 
patient  is  seriously  prostrated,  camphor,  digitalis,  and  strychnin 
will  prove  valuable  in  restoring  the  tone  of  the  vascular  s)'stem. 
Ergot  has  been  used  for  a  long  time  as  an  internal  hemostatic  in 
arresting  traumatic  and  pathologic  hemorrhage  in  cases  in  which 
local  hemostasis  can  not  be  resorted  to,  owing  to  the  source  of  the 
hemorrhage  or  the  general  condition  of  the  patient.  As  ergot 
diminishes  the  caliber  of  the  arterioles,  not  only  of  the  affected  part, 
but  all  over  the  body,  it  is  difficult  to  comprehend  its  modus  operandi 
in  arresting  hemorrhage.  From  the  physiologic  action  of  this  drug 
and  an  extensive  clinical  experience  it  is  fair  to  conclude  that  its  use 
has  done  more  harm  than  good  when  administered  for  the  purpose 
of  arresting  hemorrhage.  Its  more  legitimate  use  is  in  the  treat- 
ment of  uterine  hemorrhage  caused  by  inertia  of  the  organ.  Ergot 
acts  as  a  vasomotor  constrictor  by  its  centric  action  upon  the  vaso- 
motor centers.  Its  use  should  be  restricted  to  the  treatment  of 
hemorrhage  from  capillary  vessels,  more  especially  in  cases  where 
the  capillary  oozing  is  due  to  vasomotor  paresis.  In  such  cases  it 
exercises  a  dominant  influence  on  the  area  of  capillaries  thus  affected, 
and  its  specific  action  exerts  a  curative  influence  on  the  vasomotor 
nerves  or  unstriped  muscle-fibers  in  the  bleeding  territory  (Hare). 
Acetate  of  lead  has  been  used  for  a  long  time  as  an  internal 
remedy  in  the  treatment  of  hemorrhage  from  the  lungs  and  the 
gastro-intcstinal  canal,  but  it  is  reasonable  to  assume  that  the  arrest 
of  the  bleeding  in  most  instances  resulted  spontaneously  or  was 
favored  by  the  opium  which  is  usually  combined  with  this  drug 
when  given  as  a  hemostatic.  Of  all  internal  medicines,  perhaps 
the  most  reliable  is  oil  of  turpentine,  given  in  five-drop  doses  in 
emulsion  at  short  intervals.  The  mineral  acids,  especially  the  sul- 
phuric, so  much  in  vogue  but  a  short  time  ago  in  the  general  treat- 
ment of  hemorrhage  are  seldom  prescribed  now,  as  it  is  well  known 
that  they  have  no  influence  whatever  in  controlling  hemorrhage  by 
increasing  the  coagulability  of  the  blood  or  by  favoring  thrombus 
formation  at  the  seat  of  injury. 


134  TREATMENT    OF    HEMORRHAGE. 

gratifying  results.  Schaeffer  has  recommended  ferripyrin  in  gyne- 
cologic and  obstetric  practice  as  an  efficient  and  reliable  hemostatic. 

Antipyrin  has  been  shown  by  the  experiments  of  Park  on  ani- 
mals to  possess  valuable  hemostatic  properties.  It  was  found  that 
it  is  at  the  same  time  a  decided  antiseptic.  He  recommends  a  5  per 
cent,  solution  to  be  used  in  the  form  of  a  spray  by  compress  or  by 
injection.  It  has  been  employed  in  the  treatment  of  free  surface 
bleeding,  and  recommends  itself  more  especially  in  the  treatment  of 
obstinate  epistaxis. 

Hemorrhage  from  Bone. — Troublesome  hemorrhage  from  bone 
must  be  met  by  special  remedial  agents,  as  ligation  and  most  of 
the  other  hemostatic  resources  referred  to  are  inapplicable  in  such 
cases.  Bleeding  from  bone  in  craniectomy,  necrotomy,  resection, 
and  amputation  from  vessels  of  considerable  size  is  often  encoun- 
tered and  frequently  proves  obstinate.  The  middle  meningeal 
artery  is  occasionally  found  in  a  complete  bony  canal,  and  when 
injured,  the  bleeding  can  be  arrested  by  crushing  the  bone  around 
the  bleeding  point  with  strong  forceps  or  by  spiking  the  canal  with 
an  aseptic  bone  or  ivory  nail.  Should  such  nails  not  be  at  hand,  a 
sterilized  toothpick  or  match  can  be  used  for  the  same  purpose.  As 
wood  is  not  absorbable,  the  nail  must  be  left  long  enough  to  facili- 
tate its  subsequent  removal.  Rapin  resorted  to  ordinary  shoe-pegs 
in  arresting  hemorrhage  from  bone  in  a  case  of  resection  of  the  rec- 
tum by  Kraske's  method.  From  the  resected  surface  of  the  sacrum 
the  bleeding  was  promptly  arrested  by  driving  aseptic  pegs  into  the 
bone  at  points  from  which  the  bleeding  was  profuse.  From  one  to 
six  nails  usually  suffice  in  such  cases.  The  nails  are  extracted 
after  the  completion  of  the  operation,  but  if  the  hemorrhage  re- 
turns, they  are  again  employed  in  the  same  manner.  Riedinger 
employed  the  catgut  tampon  in  a  case  of  troublesome  hemorrhage 
from  the  tibia  after  amputation  of  the  leg.  An  artery  of  consider- 
able size  in  the  dense  compacta  was  the  source  of  the  bleeding. 
The  lumen  of  the  vessel  was  tamponed  with  pieces  of  catgut  that 
were  inserted  parallel  to  each  other,  until  the  space  was  plugged 
sufficiently  to  arrest  the  hemorrhage.  The  use  of  such  an  absorb- 
able tampon  recommends  itself  very  highly  in  arresting  hemorrhage 
from  large  vascular  spaces  in  the  cut  surface  of  the  bone.  The 
needle  point  of  the  Paquelin  cautery  at  a  dull  heat  is  an  important 
hemostatic  resource  in  arresting  hemorrhage  from  bone.  The 
eschar  created  does  not  interfere  with  a  satisfactory  healing  of  the 
wound.  If  the  bleeding  is  from  small  vessels  in  the  spongy  struc- 
ture of  the  bone,  compression  of  the  spongiosa  by  striking  it  with 
a  metallic  hammer,  forceps,  or  blunt  end  of  a  chisel  will  usually 
succeed  in  arresting  the  parenchymatous  bleeding. 

General  Treatment. — Very  little  can  be  expected  from  general 
treatment  until  the  hemorrhage  is  arrested  by  local  measures.  The 
administration  of  stimulants  of  any  kind  is  absolutely  contraindicated 
until  the  hemorrhage  is  under  control.     Any  treatment  calculated  to 


GENERAL   TREATMENT.  I35 

increase  the  heart's  action  and  to  i)itensify  the  intravascular  pressure 
must  be  carefully  avoided  as  a  source  of  danger  by  aggravating  the 
hemorrhage  and  by  atitagoiiizvig  nature' s  resources  in  effecting  spon- 
taneous arrest  of  hemorrhage.  In  some  instances  where  the  source 
of  hemorrhage  can  not  be  reached,  it  would  appear  rational  to 
pursue  an  opposite  course  and  diminish  intravascular  tension  and 
the  force  of  the  heart  muscle  by  a  timely  resort  to  the  use  of  the 
lancet.  Stimulation  is  in  place  and  urgoitly  called  for  zvJien  tJie  patient 
is  much  prostrated  from  the  loss  of  blood,  a?id  further  bleeding  has  been 
guarded  against  by  effective  hemostasis.  In  such  cases  the  use  of 
hot  wine,  or  the  more  concentrated  alcoholic  stimulants,  given  in 
decided  doses  at  short  intervals,  is  best  calculated  to  establish  speedy 
and  satisfactory  reaction.  The  body-heat  must  be  carefully  pre- 
served in  such  cases  by  the  use  of  dry  heat  applied  to  the  extremi- 
ties, and  in  grave  cases,  to  the  entire  length  of  the  trunk.  If  the 
patient  is  seriously  prostrated,  camphor,  digitalis,  and  strychnin 
will  prove  valuable  in  restoring  the  tone  of  the  vascular  system. 
Ergot  has  been  used  for  a  long  time  as  an  internal  hemostatic  in 
arresting  traumatic  and  pathologic  hemorrhage  in  cases  in  which 
local  hemostasis  can  not  be  resorted  to,  owing  to  the  source  of  the 
hemorrhage  or  the  general  condition  of  the  patient.  As  ergot 
diminishes  the  caliber  of  the  arterioles,  not  onl}^  of  the  affected  part, 
but  all  over  the  body,  it  is  difficult  to  comprehend  its  modus  operandi 
in  arresting  hemorrhage.  From  the  physiologic  action  of  this  drug 
and  an  extensive  clinical  experience  it  is  fair  to  conclude  that  its  use 
has  done  more  harm  than  good  when  administered  for  the  purpose 
of  arresting  hemorrhage.  Its  more  legitimate  use  is  in  the  treat- 
ment of  uterine  hemorrhage  caused  by  inertia  of  the  organ.  Ergot 
acts  as  a  vasomotor  constrictor  by  its  centric  action  upon  the  vaso- 
motor centers.  Its  use  should  be  restricted  to  the  treatment  of 
hemorrhage  from  capillary  vessels,  more  especially  in  cases  where 
the  capillary  oozing  is  due  to  vasomotor  paresis.  In  such  cases  it 
exercises  a  dominant  influence  on  the  area  of  capillaries  thus  affected, 
and  its  specific  action  exerts  a  curative  influence  on  the  vasomotor 
nei"ves  or  unstriped  muscle-fibers  in  the  bleeding  territory  (Hare). 
Acetate  of  lead  has  been  used  for  a  long  time  as  an  internal 
remedy  in  the  treatment  of  hemorrhage  from  the  lungs  and  the 
gastro-intcstinal  canal,  but  it  is  reasonable  to  assume  that  the  arrest 
of  the  bleeding  in  most  instances  resulted  spontaneously  or  was 
favored  by  the  opium  which  is  usually  combined  with  this  drug 
when  given  as  a  hemostatic.  Of  all  internal  medicines,  perhaps 
the  most  reliable  is  oil  of  turpentine,  given  in  five-drop  doses  in 
emulsion  at  short  intervals.  The  mineral  acids,  especially  the  sul- 
phuric, so  much  in  vogue  but  a  short  time  ago  in  the  general  treat- 
ment of  hemorrhage  are  seldom  prescribed  now,  as  it  is  well  known 
that  they  have  no  influence  whatever  in  controlling  hemorrhage  by 
increasing  the  coagulability  of  the  blood  or  by  favoring  thrombus 
formation  at  the  seat  of  injury. 


136  TREATMENT    OF    HEMORRHAGE. 

Stypticin,  one  of  the  most  recent  hemostatics,  is  hydrochlorid  of 
cotamin,  the  base  of  the  opium  alkaloid  narcotin.  It  is  a  yellow, 
inodorous,  bitter  powder,  and  is  usually  given  in  doses  of  ^  of  a 
grain  from  five  to  eight  times  a  day.  In  severe  cases  three  grains  or 
even  more  can  be  safely  administered.  It  can  also  be  given  in  10 
per  cent,  solution  in'  the  form  of  deep  intermuscular  injections.  It 
is  said  to  combine  sedative  with  the  hemostatic  properties.  It  has 
been  given  a  very  extensive  trial  in  the  Innsbruck  Gynecologic 
Qinic,  and  the  results  obtained  were  of  an  encouraging  nature. 

In  the  treatment  of  hemorrhage  in  hemophilic  patients  specific 
medication  is  always  indicated.  Inhalations  of  carbonic  dioxid  gas 
have  proved  eminently  successful  in  such  cases.  Wright  found  that 
in  a  boy  with  very  severe  hemophilia  the  coagulation  period  of  the 
blood  exceeded  fifty -four  minutes  at  a  temperature  of  18.5°  C. 
After  two-gram  doses  of  calcium  chlorid  it  was  diminished  to 
twenty -five  minutes  ;  after  a  further  similar  dose,  to  thirteen  and  a 
half  minutes.  At  a  later  period  the  normal  duration  of  coagulation 
was  fourteen  minutes,  but  after  administering  20.6  gm.  of  the  cal- 
cium chlorid  this  was  reduced  to  six  and  three-fourth  minutes. 
Copious  rectal  enemata  of  hot  normal  solution  of  salt  prove  useful, 
after  hemorrhage  has  been  arrested,  in  maintaining  the  action  of  the 
heart  and  in  relieving  the  torturing  thirst.  After  the  hemorrhage 
has  been  arrested  and  the  immediate  sources  of  danger  from  the 
loss  of  blood  have  been  met,  the  general  treatment  consists  in  re- 
storing as  speedily  as  possible  the  normal  quantity  and  quality  of 
the  blood.  Rest,  concentrated,  nutritious  diet,  and  the  administra- 
tion of  some  preparation  of  iron  are  indicated.  The  preparations  of 
iron  best  calculated  to  correct  the  acute  anemia  are  the  carbonate, 
tartrate,  citrate,  and  the  tincture  of  the  muriate.  It  is  questionable 
whether  the  use  of  bone-marrow  or  any  of  its  preparations  has 
any  positive  influence  in  inaugurating  or  favoring  the  process  of 
hematogenesis.  During  the  after-treatment  it  is  very  important  to 
protect  the  patient  as  far  as  possible  against  any  incidental  diseases, 
as  the  impoverished  condition  of  the  blood  constitutes  a  pathologic 
condition  that  would  be  sure  to  exercise  an  unfavorable  influence 
on  the  complicating  disease.  For  the  same  reasons  any  serious 
operative  intervention  should  be  postponed  in  the  absence  of  urgent 
indications  until  the  patient  has  fully  recovered  from  the  immediate 
and  remote  effects  of  the  hemorrhage. 

Autotransfusion. — Autotransfusion,  the  temporary  intravascu- 
lar displacement  of  the  blood  to  the  essential  vital  organs  by 
mechanical  means,  is  one  of  the  most  important  and  valuable  thera- 
peutic resources  in  all  cases  after  the  hemorrhage  has  been  arrested, 
and  when  life  is  threatened  from  the  loss  of  blood.  It  should  be 
resorted  to  in  all  cases  requiring  saline  infusion  in  some  form.  It 
meets  the  urgent  indications  in  the  shortest  time,  and  is  best  calcu- 
lated to  sustain  the  heart's  action  until  the  surgeon  has  time  to 
secure  and  apply  more  permanent  therapeutic  measures. 


TRANSFUSION. 


137 


Nelaton  was  the  first  one  to  call  attention  to  autotransfusion  as 
a  life-saving  procedure.  John  Hunter  bandaged  the  extremities 
from  the  periphery  to  the  base  and  made  circular  constriction  with 
a  muslin  bandage.  Gamgee's  observations,  made  on  healthy  per- 
sons used  as  subjects  for  the  experiments,  proved  that  if  one  or  both 
of  the  lower  extremities  be  rendered  bloodless  by  Esmarch's  method 
(Fig.  82)  the  heart's  action  was  increased,  a  result  which  he  attri- 
buted to  increased  intracardiac  and  intravascular  pressure  caused  by 
the  temporary  displacement  of  the  blood  and  lymph  from  the  con- 
stricted extremities. 

Autotransfusion  is  indicated  in  all  cases  of  loss  of  blood  after 
hemorrhage  has  been  arrested  and  the  general  symptoms  indicate 
an  embarrassment  of  the  general  circulation,  as  shown  by  great 
pallor,  dilated  pupils,  a  rapid,  feeble  pulse,  and  impaired  respiration. 
Autotransfusion  is  made  by  temporarily  excluding  the  circulation 
from  one  or  more  extremities.  A  certain  amount  of  autotrans- 
fusion can  be  secured  by  elevating  the  foot  of  the  bed  so  as  to  in- 
cline the  body   at   an   angle  of  at  least  45  degrees.      In  making 


Fig.  82. — Autotransfusion  (Esmarch). 


autotransfusion  proper,  the  extremity  to  be  constricted  must  be 
placed  and  held  in  a  vertical  position  long  enough  to  render  it 
practically  bloodless, — that  is,  from  three  to  five  minutes, — when 
its  base  is  constricted  with  an  elastic  band,  tube,  or  cord  in  the 
same  manner  as  has  been  described  under  the  head  of  prophylactic 
hemostasis.  In  this  manner,  according  to  the  severity  of  the 
symptoms,  one,  two,  or  all  of  the  extremities  arc  excluded  from 
the  circulation  long  enough  to  gain  sufficient  time  for  the  employ- 
ment of  more  permanent  therapeutic  measures.  It  is  perfectly  safe 
to  exclude  a  limb  from  the  circulation  for  at  least  two  hours. 
Whenever  it  becomes  necessary  to  maintain  the  essential  intra- 
vascular tension  by  this  procedure  for  a  longer  period,  the  limbs  can 
be  alternately  constricted. 

Transfusion. — The  results  of  experimentation,  as  well  as  a 
large  clinical  experience,  do  not  sustain  the  hopes  entertained  con- 
cerning the  therapeutic  value  of  transfusion  in  cases  in  which  life 
is  placed   in   jeo[)ardy   by   hemorrhage.      This  ap[)lies    with  equal 


138  TREATMENT    OF    HEMORRHAGE. 

force  to  the  transfusion  of  whole  blood  from  any  of  the  lower  ani- 
mals and  man,  as  well  as  the  use  of  defibrinated  blood.  Direct 
transfusion  is  attended  by  so  much  risk  from  thrombosis  and  em- 
bolism that  it  is  seldom  resorted  to  at  the  present  time.  Fever 
and  hematuria  are  such  constant  sequela;  of  transfusion  that  we 
are  forced  to  the  conclusion  that  the  transfused  blood,  either  whole 
or  defibrinated,  plays  the  part  of  a  foreign  substance  which  is  des- 
tined, if  the  patient  survives  the  ordeal,  to  become  eliminated 
through  the  various  routes  designed  for  such  function.  It  is  ques- 
tionable if  in  successful  cases  the  transfused  blood  is  of  more  use  in 
saving  life  than  an  equal  amount  of  the  normal  saline  solution  which 
has  at  the  present  time  taken  the  place  almost  entirely  of  transfusion 
and  infusion  of  defibrinated  blood. 

Saline  Infusion.— The  intravenous  infusion  of  milk  has  only  a 
historic  interest  at  this  time.  It  has  been  shown  conclusively  that 
death  from  hemorrhage  takes  place  in  consequence  of  a  loss  of 
intracardiac  and  intravascular  pressure,  incompatible  with  the  func- 
tion of  the  circulatory  organs.  It  has  also  been  ascertained  by  ex- 
periments and  an  extensive  clinical  experience  that  the  circulation 
can  be  maintained  by  increasing  the  intravascular  tension  to  the 
required  degree  by  substituting  for  the  blood  lost  an  equivalent 
quantity  of  normal  salt  solution.  The  solution  usually  employed 
is  a  3^  of  I  per  cent,  solution  of  chemically  pure  chlorid  of  sodium. 
The  solution  can  be  extemporized  by  dissolving  a  teaspoonful  of 
salt  in  a  pint  of  sterile  water.  Szumann  recommends  the  addition 
of  carbonate  of  soda. 

Szumann' s  Saline  Solution.- — 

Sodium  chlorid, 6  parts 

Sodium  carbonate, i  part 

Distilled  water, 1000  parts. 

The  value  of  a  rather  high  temperature  of  the  saline  infusion 
was  demonstrated  conclusively  by  Dawbarn's  experiments  on  dogs. 
He  used  the  kymograph,  a  giant  sphygmograph,  to  determine  the 
effect  on  the  blood  pressure  in  using  solutions  of  different  tempera- 
tures. He  is  of  the  opinion  that  the  temperature  should  not  be 
lower  than  120°  F.  It  has  been  shown  that  a  temperature  of 
160°  F.  is  necessary  in  order  to  coagulate  any  of  the  albuminoid 
ingredients  of  the  body.  A  thermometer  in  emergency  practice  is 
not  always  available,  and  it  has  been  shown  that  a  sufficient  degree 
of  accuracy  in  determining  the  proper  temperature  of  the  solution  to 
be  used  is  obtained  by  means  of  the  hand.  A  temperature  of  the 
solution  at  which  the  hand  can  be  immersed  without  much  discom- 
fort is  the  one  adapted  for  making  an  intravenous  infusion.  The 
saline  infusion  can  be  administered  by  three  different  routes,  according 
to  the  urgency  of  the  symptoms — by  the  rectum,  hypodermically,  and 
directly  into  one  of  the  larger  veins.  The  rectum  absorbs  the  salt 
solution  very  promptly,  more  rapidly  than  plain  water,  and  in  cases 
in  which  the  symptoms  are  not  grave  this  is  the  proper  route  to 


SALINE    INFUSION. 


139 


select.  From  one  to  two  quarts  of  the  solution  can  be  given  every 
two  or  three  hours  until  the  necessary  degree  of  intravascular  ten- 
sion has  been  reached.  In  graver  cases  the  solution  is  adminis- 
tered subcutaneously,  infusing  from  a  pint  to  a  quart  at  a  time,  and 


^'K-  ^3- — Subcutaneous  saline  infusion. 

repeating  the  procedure  every  hour  or  two  until  a  sufficient  quan- 
tity has  been  used.  All  that  is  necessary  for  making  the  subcu- 
taneous infusion  are  a  small  trocar  and  an  irrigator  to  whicii  a  piece 


I40 


TREATMENT    OF    HEMORRHAGE. 


of  rubber  tubing  from  four  to  six  feet  in  length  is  attached.  In  the 
absence  of  an  irrigator  any  kind  of  a  vessel  can  be  used,  the  fluid 
being  infused  by  siphonage.  For  the  puncture,  localities  are  selected 
where  the  subcutaneous  tissue  is  abundant  and  loose,  as  the  mam- 
mary and  interscapular  regions,  the  abdomen,  or  the  inner  surface 
of  the  thigh  (Fig.  8^)-  If  the  infusion  is  repeated,  a  new  locality  is 
selected  at  each  sitting.  The  point  of  puncture  should  be  properly 
disinfected,  and  the  trocar  must  be  rendered  sterile  by  boiling.  The 
rubber  tube  is  filled  with  the  solution  before  it  is  connected  with 
the  cannula,  after  which  the  reservoir  is  held  or  suspended  from 
three  to  six  feet  above  the  point  of  puncture.  The  diffusion  of  the 
fluid  through  the  connective -tissue  spaces  is  hastened  by  pressure 
and  kneading.    The  puncture  is  sealed  with  collodion  after  removal 

of  the  cannula.     In 
f  grave  cases  the  in- 

travenous route  is 
the  one  that  will 
yield  the  quickest 
and  most  reliable 
results. 

In  amputations 
and  in  other  opera- 
tions where  large 
veins  are  wounded 
the  injection  can 
be  made  through 
the  wounded  vein. 
Nothing  is  gained 
by  making  an  intra- 
arterial in  place  of 
an  intravenous  in- 
fusion. Ordinarily 
the  median  basilic 
vein  is  selected  to 
receive  the  solution.  The  flexor  side  of  the  elbow  region  is  care- 
fully disinfected,  after  which  a  bandage  is  applied  above  the  elbow 
sufficiently  tight  to  obstruct  the  circulation  in  the  superficial  veins 
in  the  same  manner  and  for  the  same  purpose  as  in  performing 
phlebotomy.  The  vein  is  then  exposed  by  making  an  incision 
over  it  long  enough  to  afford  ample  room  during  the  remaining 
steps  of  the  operation.  The  incision  is  made  to  reach  the  adipose 
tissue,  between  the  skin  and  the  vein,  which  is  then  torn  through 
with  a  blunt  instrument  and  the  vein  exposed.  The  vein  is  isolated 
rapidly,  and  two  fine  catgut  ligatures  are  placed  underneath  it. 
One  of  the  ligatures  is  tied  at  the  lower  angle  of  the  wound.  The 
vein  above  this  ligature  is  then  incised  obliquely,  making  an  open- 
ing large  enough  to  admit  the  cannula  or  glass  tip  of  the  infusor. 
The  second  ligature  is  then  drawn  over  it  tightly  enough  to  pre- 


Fig.  84.- 


-Intravenous  saline  infusion.      Manner  of  incising 
vein  and  inserting  glass  tube. 


SALINE    INFUSION. 


141 


vent  the  escape  of  blood  ;  its  ends  are  crossed  and  held  by  an 
assistant  until  the  infusion  is  completed,  when  it  is  used  as  a  liga- 
ture above  the  wound.  The  infusion  is  made  slowly  and  continued 
until  the  character  of  the  pulse  indicates  that  the  necessary  degree 
of  intravascular  pressure  has  been  reached.  From  one  pint  to 
more  than  a  quart  of  the  solution  is  required  in  all  cases  that  war- 
rant the  choice  of  the  intravenous 
route.  If  in  the  course  of  an 
hour  the  patient  does  not  rally, 
the  intravenous  infusion  is  re- 
peated, or  perhaps  during  this 
time  a  sufficient  quantity  of  the 
saline  solution  can  be  introduced 
by  the  subcutaneous  or  rectal 
route,  to  obviate  the  necessity  of 
reopening  the  vein. 

The  employment  of  the  saline 
solution  as  a  substitute  for  direct 
transfusion  or  infusion  marks  one 
of  the  recent  and  greatest  ad- 
vances in  surgery,  and  as  such 
deserves  a  most  extended  recog- 
nition on  the  part  of  the  profes- 
sion.    The  procedure  is  so  simple 

and  the  results  are  so  gratifying  that  no  patient  whose  life  is  in 
danger  from  the  loss  of  blood  should  be  left  for  any  length  of  time 
without  a  recourse  to  saline  infusion  by  one  or  more  of  the  routes 
indicated.  Intraperitoneal  infusion,  for  reasons  not  necessary  to 
enumerate,  has  been  relegated  to  the  past,  having  been  superseded 
entirely  by  intravenous,  subcutaneous,  or  rectal  infusion. 


Fig.  85. — Manner  of  making  infusion. 


CHAPTER  VI. 

WOUNDS. 

A  CAREFUL  Study  of  the  etiology,  nature,  manner  of  healing,  in- 
fection, and  treatment  of  wounds  is  an  essential  prerequisite  to  the 
successful  practice  of  surgery.  The  surgeon's  daily  work  brings 
him  constantly  in  touch  with  wounds  which  he  either  inflicts  inten- 
tionally or  which  he  is  expected  to  treat.  The  success  of  his  work 
will  depend  largely  on  his  ability  to  minimize  by  his  efforts  the 
reparative  work  of  the  tissues  injured,  and  to  protect  the  patient 
against  immediate  and  remote  complications.  Less  than  fifty  years 
ago  the  surgeon  assumed  but  little  responsibility  when  he  under- 
took the  treatment  of  a  recent  wound,  because  both  the  profession 
and  the  public,  as  the  result  of  experience  and  observation  from  the 
time  when  wounds  were  first  inflicted  and  dressed,  expected  sup- 
puration, and  they  had  become  accustomed  to  the  frequency  with 
which  infected  wounds,  regardless  of  their  location  and  size,  gave 
rise  to  erysipelas,  progressive  phlegmonous  inflammation,  purulent 
edema,  sloughing,  gangrene,  sepsis,  pyemia,  and  hospital  gangrene. 
Dupuytren's  pessimistic  confession,  "  Je  le  pansay,  Dieu  le  guerit," 
expresses  well  the  total  helplessness  of  the  surgeon  in  protecting 
wounds  against  infection  before  Lister  raised  the  curtain  which  for 
several  thousand  years  had  held  in  utter  darkness  the  mystery  of 
wound  infection.  Many  earnest  attempts  had  been  made  to  pene- 
trate this  veil,  but  all  in  vain  until  the  microbic  nature  of  the  differ- 
ent wound  complications  became  established  through  the  epoch- 
making  researches  of  Pasteur,  Lister,  Ogston,  Koch,  and  their 
numerous  coworkers  and  followers. 

Judging  from  the  present  standpoint  of  wound  infection,  it  is  not 
surprising  that  formerly  so  few  wounds  healed  by  primary  intention, 
but  rather  it  appears  almost  miraculous  that  so  many  of  the  injured 
escaped  with  their  lives.  All  the  large  hospitals  became  death-traps 
in  which  patients  often  lost  their  lives  from  insignificant  injuries  and 
the  most  trivial  operations.  We  can  imagine  the  feelings  of  the 
surgeons  when  they  saw  their  patients  die  from  erysipelas  following 
a  small  scalp  wound,  or  found  themselves  powerless  to  prevent 
death  from  sepsis  or  pyemia  after  the  removal  of  a  fatty  tumor  or 
the  extirpation  of  a  ganglion  from  the  tendon  sheaths  ;  and  yet 
such  terrible  experiences  were  by  no  means  rare.  If  we  recollect 
that  even  ordinary  cleanliness  in  those  days  was  often  foreign  to 
surgical  practice,  we  can  readily  understand  that  the  life  of  every 
patient  the  subject  of  an  open  injury  was  in  danger,  and  that  in  all 
probability  in  many  instances  the  danger  was  rather  increased  than 

142 


WOUNDS.  143 

diminished  by  surgical  intervention.  At  the  present  day  the  re- 
hearsal of  such  scenes  makes  us  shudder,  and  a  sense  of  horror  is 
felt  when  we  follow  the  footsteps  of  the  surgeon  of  fifty  years  ago. 

Hand  disinfection  was  not  known  at  that  time  ;  we  can  see  him 
operate  with  hands  ornamented  by  precious  rings,  with  finger-nails 
untrimmed,  and  the  ominous  death-dealing  black  line  underneath. 
We  observe  him  take  his  instruments,  used  but  recently  in  perform- 
ing an  amputation  for  purulent  edema,  from  a  velvet-lined  case, 
and,  without  any  preparation  whatever,  use  them  again  in  excising 
a  carcinomatous  breast.  Probably  the  same  sponges  that  had  done 
service  in  dressing  an  ulcer  of  the  leg  are  used  in  wiping  the  bleed- 
ing surface.  The  only  fluid  that  is  brought  in  contact  with  the 
wound  is  cold  water  of  doubtful  source,  and  in  a  basin  that  has 
made  its  rounds  from  patient  to  patient.  Watch  him  tie  the  bleeding 
vessels.  He  has  no  hemostatic  forceps  ;  with  a  sharp  hook  he  picks 
up  a  cone  of  tissue  with  the  bleeding  vessel  in  the  center.  A  kw  silk 
ligatures,  which  he  waxed  thoroughly  before  he  commenced  the 
work,  are  lying  on  the  .stand  close  by.  He  grasps  the  nearest  one 
and  applies  it  to  the  base  of  the  cone,  and  ties  with  all  the  force  at 
his  command,  crushing  the  tissues  underneath  the  thread,  which 
soon  lies  knotted  and  buried  underneath  the  little  p)'ramid  of  devi- 
talized tissue  ;  one  end  is  cut  short  to  the  knot,  the  other  is  left 
hanging  out  of  the  wound.  After  hemorrhage  has  been  controlled 
the  wound  is  again  sponged  and  closed  with  a  few  points  of  suture 
of  the  same  material,  and  a  cold-water  compress  constitutes  the 
dressing. 

There  are  many  surgeons  still  living  who  operated  in  the  man- 
ner just  described.  Does  it  seem  strange  that  such  wounds  sup- 
purated ?  Does  it  not  appear  stranger  that  so  many  injured  and 
operated  upon,  after  a  long  struggle  with  secondary  hemorrhage, 
suppuration,  and  fever,  finally  escaped  with  their  lives  ?  The  chills, 
the  feverish  brow,  the  dry  tongue,  the  parched  lips,  the  feeble,  rapid 
pulse,  the  muttering  delirium,  the  swollen,  edematous  limbs,  the 
faces  disfigured  beyond  recognition  by  erysipelas,  the  streams  of 
pus,  and  the  ravages  of  hospital  gangrene  seen  on  all  sides  in  the 
crowded  insanitary  hospitals  of  but  one  generation  ago  have 
happily  nearly  disappeared,  and  are  seldom  seen  as  unwelcome  and 
unexpected  visitors  in  our  modern  ho.spitals.  The  surgeon  of  to- 
day, if  he  does  his  duty  before  as  well  as  during  an  operation,  can 
perform  tiie  gravest  operations  without  fear  of  rendering  his  nights 
hideous  by  the  ringing  of  the  doorbell  by  messengers  summoning 
him  to  arrest  secondary  hemorrhage  or  to  combat  the  stormy 
symptoms  announcing  the  beginning  of  a  grave  form  of  wound 
infection.  What  a  contrast  in  the  methods  and  results  of  the  sur- 
gery of  our  day  with  that  of  our  forefathers  !  To-day  we  can  say 
with  Nussbaum,  "  T/ie  fate  of  the  wounded  rests  in  the  hands  of  the 
one  who  applies  the  first  dressing.''  If  this  is  true,  and  there  are 
{i^\v,  if  any,  who  would  not  indorse  the  correctness  of  this  state- 


144 


WOUNDS. 


ment  by  word  and  action,  it  is  plain  that  the  marvelous  improve- 
ments in  the  treatment  of  wounds  have  brought  upon  the  surgeon 
additional  grave  responsibilities. 

The  innovations  that  have  made  surgery  what  it  is  at  the  present 
time  consist  mainly  in  placing  at  the  disposal  of  those  who  practise 
the  art,  ways  and  means  to  guard  effectually  against  wound  infec- 
tion. A  clear  conception  of  the  nature  and  conditions  of  life  of  the 
living  agents  that  cause  infection,  their  source  and  mode  of  entrance 
into  wounds,  and  their  action  on  the  tissues  is  essential  to  the  ac- 
quirement of  a  clear  understanding  of  the  methods  employed  in 
preventing  infection.  In  standing  guard  for  a  recent  wound,  the 
surgeon  has  to  contend  with  foes  that  are  invisible  to  the  naked 
eye  and  that  approach  the  wound  from  all  sides.  If  he  expects  to 
do  effective  duty,  he  must  be  familiar  with  the  location  of  the 
enemy,  his  strength  and  source  of  supply,  and  make  the  attack  at 
the  right  time  and  in  the  right  place.  The  surgeon  must  be  on  the 
offensive  if  he  expects  to  win,  as  a  defensive  course  means  a  des- 
perate struggle  and  often  an  ignominious  defeat.  Our  weapons  are 
numerous  and  variable, — the  methods  of  warfare  manifold, — but  the 
object  of  them  all  should  be  to  destroy  or  render  harmless  the 
enemy  before  he  takes  possession  of  the  wound.  The  modern 
science  of  bacteriology  is  the  surgeon's  handbook  on  tactics  in 
conducting  such  warfare,  and  unless  he  is  perfectly  familiar  with  its 
contents,  his  movements  will  be  uncertain  and  his  attacks  hap- 
hazard, firing  at  an  enemy  ambushed  in  a  jungle.  The  surgeon 
must  know  the  sources  of  danger  and  know  how  to  avoid  them. 

It  is  my  purpose  to  discuss  in  this  section  open  wounds,  in- 
tentional and  accidental,  with  special  reference  to  the  methods 
of  modern  treatment.  The  classification  of  wounds  has  a  direct 
bearing  on  the  course  of  treatment  that  should  be  pursued. 
The  size  of  the  wound  should  not  be  made  a  standard  to  de- 
termine the  risk  incident  to  the  injury  and  the  degree  of  care 
necessary  in  its  treatment,  as  large  wounds  often  heal  promptly, 
and  small  wounds  may  result  in  dangerous  complications.  We 
see  to-day  some  of  the  results  of  the  old  methods  of  wound 
treatment  in  cases  in  which  the  injury  is  treated  by  laymen  or 
by  physicians  who  do  not  appreciate  the  importance  of  resorting 
to  painstaking  aseptic  precautions  in  the  treatment  of  insignificant 
accidental  wounds.  Golebieski  has  recently  published  an  article  in 
which  he  reports  the  more  or  less  serious  results  following  slight 
injuries  of  the  hand  and  fingers,  which  were  at  first  treated  by  the 
patients.  In  all,  70  cases  are  reported.  Of  13  injuries  of  the 
thumb,  permanent  disability  resulted  in  60  per  cent.,  and  the  average 
loss  of  time  during  treatment  was  thirty-three  weeks.  Recovery 
of  perfect  function  of  the  hand  resulted  in  9  out  of  1 5  cases,  but 
the  average  duration  of  treatment  was  twenty  weeks.  It  is  super- 
fluous to  quote  further  from  this  source  ;  the  serious  and  even 
fatal  results  that  sometimes  follow  slight  injuries  are  well  known  to 


INCISED    WOUNDS.  I45 

all  who  are  familiar  with  the  practice  of  large  out-patient  depart- 
ments and  dispensaries.  In  view  of  such  facts  it  seems  strange 
that  physicians  do  not  take  better  care  of  themselves  ;  the  very  men 
who  are  familiar  with  the  risks  that  often  attend  slight  injuries  and 
are  most  exposed  by  constantly  coming  in  contact  with  all  kinds  of 
pathogenic  microbes  are  often  the  most  careless.  Every  physician 
certainly  owes  it  to  himself  and  to  those  possibly  dependent  upon 
his  life  and  labor  to  keep  in  mind  the  serious  cases  of  infection 
which  are  so  common  in  our  profession,  and  to  disinfect  carefully 
and  protect  even  the  slightest  abrasions.  It  is  well  known  that 
slight  injuries  of  the  hands  and  feet  are  followed  by  tetanus  more 
frequently  than  large  wounds,  and  the  only  explanation  for  this  is 
that  such  wounds  are  too  frequently  neglected  by  the  patients  or, 
when  a  physician  is  called,  they  do  not  receive  the  attention  their 
importance  demands.  The  usefulness  of  thousands  of  fingers  is  lost 
annually  from  slight  injuries  and  careless  treatment.  Insignifi- 
cant penetrating  wounds  of  the  knee-joint  and  other  large  joints 
have  filled  many  graves,  have  resulted  in  the  loss  of  many  limbs, 
and  have  left  innumerable  ankylosed  joints  and  useless  limbs.  It 
may  be  said  that  no  wounds  are  too  large  to  be  despaired  of,  and 
none  too  small  to  be  overlooked  or  neglected.  Any  trauma  that 
results  in  a  loss  of  continuity  of  the  skin  creates  an  infection  atrium 
through  which  pathogenic  microbes  may  find  their  way  into  the 
tissues  and  through  the  lymphatics  and  general  circulation  to  any 
part  of  the  body.  It  is  the  duty  of  the  surgeon  to  protect  all  such 
surfaces  of  absorption  against  the  entrance  of  microbes  until,  by  a 
process  of  repair,  the  continuity  of  the  injured  surface  has  been 
restored.  The  numerous  l\'mphatic  channels  in  the  skin  render 
superficial  wounds  liable  to  streptococcus  infection,  with  all  the  pos- 
sibilities which  may  arise  from  such,  and  for  this  reason  should 
never  be  overlooked  or  slighted.  From  an  etiologic  standpoint 
wounds  are  classified  into  (i)  incised,  (2)  lacerated,  (3)  contused,  (4) 
stab,  (5)  punctured,  (6)  gunshot,  and  (7)  poisoned. 

I.  Incised  wounds  are  inflicted  by  sharp  cutting  instruments. 
The  best  examples  are  furnished  by  wounds  inflicted  by  the  sur- 
geon's knife.  The  surfaces  of  the  wound  are  smooth  and  bleed 
freely  in  consequence  of  the  division  of  numerous  vessels  by  a 
clean  cut.  In  large  wounds  the  margins  retract  freely  if  any  of 
the  muscles  have  been  divided  to  any  extent  transversely,  other- 
wise the  amount  of  gaping  will  depend  on  the  size  and  depth  of  the 
wound  and  the  degree  of  cla.sticity  of  the  severed  tissues.  The 
e.xtent  of  the  injury  can  be  ascertained  more  readily  and  with  a 
greater  degree  of  accuracy  in  incised  than  in  any  other  kind  of 
wounds,  as  the  injured  tissues  are  open  to  in.spection  and  palpation, 
and  the  trauma  is  limited  to  the  line  of  the  cut  or  incision.  They 
are  also  more  easily  disinfected  than  wounds  made  by  penetrating 
or  blunt  implements.  Foreign  bodies  arc  .seldom  overlooked,  and 
the  free  bleeding  docs  its  share  in  the  mechanical  removal  of 
10 


146 


WOUNDS. 


microbes  and  infected  substances.  Incised  wounds  present  also 
the  most  favorable  conditions  for  the  accurate  coaptation  of  the 
same  anatomic  structures  by  mechanical  means— suturing,  position, 
compression,  and  immobilization.  It  is  in  the  mechanical  treat- 
ment of  such  injuries  that  the  careful  surgeon  exercises  his  skill, 
with  a  view  to  obtaining  an  ideal  functional  result  by  uniting,  with 
buried  absorbable  sutures,  tendon  to  tendon,  nerve  to  nerve,  muscle 
to  muscle,  fascia  to  fascia,  and  skin  to  skin,  and  by  placing  the 
injured  part  in  a  position  that  will  minimize  the  tension  on  the  deep 


Fig.  86. — Muscle  suture  :  A,  Transverse  wound  of  biceps  muscle,  showing  marked  re- 
traction of  muscle-ends  and  mattress  suture  in  place  ;  £,  muscle  suture  completed. 


sutures  and  immobilize  it  for  the  purpose  of  securing  rest  until  the 
process  of  repair  has  advanced  sufficiently  to  obviate  the  necessity 
for  further  use  of  mechanical  supports.  Recent  incised  wounds 
seldom  demand  drainage  if  by  the  use  of  buried  sutures  and  other 
mechanical  measures  the  formation  of  so-called  dead  spaces  can  be 
prevented.  The  time  required  for  the  healing  of  an  aseptic  incised 
wound  depends  largely  on  the  degree  of  vascularity  and  compact- 
ness of  the  injured  tissues.  Wounds  of  the  face,  lips,  tongue,  and 
scalp  heal  in  a  remarkably  short  time,  while  wounds  of  the  trunk 


LACERATED    WOUNDS. 


147 


and  extremities  above  the  hands  and  feet  require  a  much  longer 
period.  It  is  important  to  remember  this  in  estimating  the  time  for 
the  removal  of  sutures.  In  wounds  of  the  first-named  localities 
the  sutures  can  often  be  safely  removed  at  the  end  of  from  three  to 
five  days,  while  in  the  latter  locations  they  must  remain  two  or 
three  times  as  long  to  fulfil  the  indications  for  which  they  were 
employed. 

2.  Lacerated  wounds  are  made  by  tearing  caused  by  traction 
force.  The  most  familiar  illustrations  of  this  injury  are  furnished 
by    machinery    accidents    and    wounds    resulting    from    dragging. 


Fig.  87. — Muscle  suture  :   A,  Suturing  of  sheath  of  biceps  :   B,  suturing  completed. 


Hemorrhage  in  such  cases  is  slight,  even  when  vessels  of  the  size  of 
the  femoral  or  axillary  artery  are  torn  across.  It  is  often  difficult 
to  determine,  even  on  careful  examination,  the  extent  of  the  injury 
and  the  parts  involved,  as  the  size  of  the  external  wound  does  not 
always  correspond  with  the  extent  of  the  subcutaneous  injury.  It 
is  in  such  cases  that  the  surgeon  must  seek  for  peripheral  manifes- 
tations indicating  the  existence  of  injury  to  important  vessels  and 
nerves. 

Large  nerves  may  be  torn  across  or  otherwise  seriously  injured 


148 


WOUNDS. 


some  distance  from  the  wound,  and  complications  of  this  kind  are 
often  overlooked  unless  careful  examination  is  made  at  the  time  in 
reference  to  nerve  function  below  the  wound.  An  artery,  by  trac- 
tion force  stopping  short  of  a  complete  transverse  tear,  may  become 
subsequently  impermeable  by  laceration  of  the  intima,  an  accident 
that  can  be  recognized,  or  at  any  rate  suspected,  by  an  enfeebled 
arterial  circulation  below  the  injury,  and,  as  has  been  shown  by 
von  Wahl,  by  a  bruit  over  the  seat  of  the  torn  intima.  Torn 
wounds  are  irregular  in  their  outline — the  margins  of  the  skin  are 
ragged  and  frequently  inverted.  Muscles,  tendons,  and  fascia  yield 
at  the  point  of  least  resistance,  and  the  planes  of  laceration  of  the 
different  structures  seldom  correspond.  As  lacerated  wounds  are 
always  caused  by  accident,  they  must  be  regarded  as  infected 
wounds  and  treated  as  such. 

The  buried  suture  has  only  a  limited  field  of  usefulness  in  the 
treatment  of  lacerated  wounds.  By  trimming  the  margins  of  the 
torn  skin,  and  by  removing  torn  tissue  hopelessly  destroyed  by  the 
injury  underneath  it,  the  surgeon  makes  attempts  to  transform,  as 
nearly  as  he  can,  a  lacerated  into  an  incised  wound,  for  more  effec- 
tive suturing,  and  with  a  view  to  expediting  the  healing  of  the 
wound  and  with  the  expectation  of  securing  better  functional  results. 
In  the  majority  of  cases  drainage  becomes  a  necessity,  as  primary 
disinfection  is  less  reliable  and  as  suturing  can  not  be  done  with  the 
same  degree  of  accuracy  as  in  incised  wounds. 

3.  Contused  wounds  are  the  result  of  the  direct  application  of 
blunt  force  to  the  seat  of  injury.  Wounds  made  by  kicks,  blows, 
or  the  passage  of  a  wheel  of  any  kind  of  vehicle,  from  a  light  buggy 
to  a  railway  car,  present  the  most  familiar  illustrations  of  injuries  of 
this  kind.  The  appearance  of  a  contused  wound  depends  on  the 
size  of  the  vulnerating  implement  and  the  degree  offeree  with  which 
it  is  applied,  the  character  of  the  soft  tissues  injured,  and  their  re- 
lation to  the  underlying  bone.  The  force  that  produces  the  con- 
tusion not  infrequently  causes  more  or  less  laceration  if  it  strikes 
the  injured  part  obliquely,  when  the  resulting  wound  presents  the 
appearances  of  a  contused  lacerated  wound.  It  is  in  such  instances 
that  the  skin  is  often  found  extensively  separated  from  the  under- 
lying lacerated  and  contused  tissues.  Crushing  injuries,  such  as 
are  produced  in  railway  accidents,  are  contused  wounds  of  the 
highest  degree,  in  which  not  only  the  soft  tissues  are  almost  pulpi- 
fied,  but  the  bones  are  likewise  comminuted — crushed  into  small 
fragments.  The  skin  is  likely  to  be  the  structure  principally  in- 
volved if  the  wound  is  inflicted  where  it  lies  almost  directly  upon 
the  bone,  as  is  the  case  with  the  scalp,  the  skin  over  the  spine  of 
the  tibia,  the  bony  prominences  near  joints,  the  crest  of  the  ilium, 
or  the  surface  of  the  sacrum.  In  other  localities  the  extent  of  in- 
jury to  the  skin  is  often  very  deceptive  in  estimating  the  size  and 
gravity  of  the  injury,  owing  to  its  great  elasticity,  as  is  the  case  in 
crushing  injuries  of  the  limbs.      Contused  wounds  are  most  liable 


CONTUSED    WOUNDS. 


149 


to  infection,  as  the  vulnerating  implement  usually  conveys  into  the 
wound  foreign  material, — infected  substances, — and  its  effect  on 
the  tissues  is  such  as  to  destroy  their  vitality  over  a  greater  or 
less  extent,  and  reduces  the  power  of  resistance  to  infection  of  the 
adjacent  tissues. 

As  in  lacerated,  so  in  contused  wounds,  the  surgeon  is  often 
compelled  to  judge  the  extent  of  the  injury  by  a  careful  examination 
of  the  functional  disturbances  of  muscles,  nerves,  and  vessels  below 
the  seat  ot  the  injur}-,  or  in  the  territories  near  it  supplied  with  these 
structures,  which  ma}'  be  involved  at  the  seat  of  trauma.  From  a 
practical  standpoint,  every  contused  wound  must  be  considered  as 
an  infected  wound. 
Foreign  bodies  must 
be  searched  for  and 
removed  ;  tissues 
that  have  lost  their 
vitality  in  conse- 
quence of  the  im- 
mediate effect  of  the 
injur}'  must  be  re- 
moved. Energetic 
primary  disinfection 
is  an  urgent  neces- 
sity. As  a  rule,  very 
little  can  be  done  in 
the  way  of  diminish- 
ing the  size  of  the 
wound  b}'  suturing. 
Drainage  is  always 
indicated.  Unless 
the  wound  is  a  small 
one,  healing  at  best 
is  delayed,  and  ulti- 
mately takes  place 
by  massive  granula- 
tions that  result  in 
the  formation  of  an 
irregular  scar  which 

in  size  seldom  indicates  even  approximately  the  extent  of  the  original 
wound.  The  functional  result  is  usually  far  less  satisfactory  than 
that  which  follows  an  incised  wound  in  the  same  locality  and  of  the 
same  size,  for  reasons  that  are  too  obvious  to  require  mention. 
Hemorrhage  is  slight  or  almost  entirely  absent  in  contused  wounds, 
as  the  blood-vessels  implicated  in  the  wound  are  crushed,  a  condi- 
tion best  adapted  for  the  prevention  and  spontaneous  arrest  of  hemor- 
rhage. If  any  of  the  large  intracranial  sinuses  are  involved  in  the 
injury,  hemorrhage  may  be  profuse  and  rccpiire  prompt  interference 
on  the  part  of  the  surgeon,  as  in  such  instances  the  contusion  of  the 


Fig.  88. — Crushing  of  foot  l)y  a  railway  injury. 


ISO 


WOUNDS. 


soft  tissues  seldom  succeeds  in  obliterating  the  lumen  of  the  injured 
vessel. 

4.  Stab  wounds  are  produced  by  the  penetration  of  the  tissues 
by  the  blade  of  a  knife,  scissors,  saber,  or  any  other  narrow,  sharp 
instrument.  They  are  characterized  by  the  small  size  of  the  wound 
at  the  point  of  entrance  of  the  vulnerating  instrument  and,  unless  the 
implement  has  transfixed  the  injured  part,  by  their  unknown  depth. 
In  width  and  length  they  correspond  in  size  to  the  portion  of  the 
blade  that  penetrated  the  tissues.  If  vessels  of  any  considerable 
size  are  injured,  troublesome  hemorrhage  takes  place  and  traumatic 
aneurysm  frequently  follows  as  an  immediate  or  remote  complica- 
tion. The  latter  result  is  more  liable  to  occur  if  an  artery  is  punc- 
tured or  only  severed  in  part.  Stab  wounds  involving  any  of  the 
large  blood-vessels  may  result  in  death  in  a  very  short  time. 
Hemorrhage  is  often  internal,  as  in  penetrating  wounds  of  the  chest 
implicating  the  internal  mammary  and  intercostal  arteries,  and  when 
the  deep  epigastric  artery  is  cut  in  penetrating  wounds  of  the  abdo- 
men. Stab  wounds  differ  from  gunshot  wounds  in  that  the  bones 
are  seldom  injured  to  any  extent,  with  the  exception  of  the  cranial 
bones  and  ribs  in  penetrating  wounds  of  the  skull  and  chest,  and 
the  greater  frequency  with  which  hemorrhage  is  encountered.  In 
stab  wounds  of  the  skull,  chest,  abdomen,  and  in  the  vicinity  of 
large  joints,  it  is  often  difficult  to  determine  whether  or  not  the 
wound  is  a  penetrating  one. 

In  the  absence  of  symptoms  pointing  to  a  visceral  injury 
sufificiently  grave  to  demand  operative  interference,  the  treatment 
should  be  directed  exclusively  to  the  prevention  of  infection  by 
appropriate  aseptic  precautions.  Stab  wounds  are  straight  and,  as 
a  rule,  clean,  and  usually  heal  rapidly  under  the  most  conservative 
treatment.  It  is  always  well  to  secure  and  examine  the  instrument 
with  which  the  injury  was  inflicted,  as  in  the  event  of  the  knife- 
blade  striking  a  bone,  a  part  of  the  blade  may  break  off  and  remain 
undetected  in  the  tissues.  If  the  knife  can  not  be  found,  and  such 
an  accident  is  suspected,  the  Rontgen  ray  is  the  safest  and  most 
reliable  diagnostic  resource.  Digital  exploration  and  probing  are 
inadmissible,  as  these  procedures  add  little  to  our  knowledge  of 
the  extent  and  gravity  of  the  injury  and  always  increase  the  risk 
of  infection.  If  it  becomes  necessary  to  resort  to  surgical  inter- 
vention for  the  purpose  of  instituting  direct  treatment  of  injuiy 
to  vessels,  nerves,  or  any  of  the  internal  viscera,  the  wound  canal 
is  enlarged  sufficiently  by  incision  to  give  ready  access  to  the  cut 
vessel,  nerve,  or  injured  organ  to  meet  the  existing  local  indication. 
In  the  absence  of  any  such  indications  the  first-aid  dressing  is 
applied  under  the  usual  aseptic  precautions,  and  must  remain  in 
place  until  the  wound  is  healed  or  symptoms  indicate  the  existence 
of  infection. 

5.  Punctured  wounds,  such  as  are  made  by  needles,  pens,  pen- 
holders, pencils,  bayonets,  etc.,  are  characterized  by  slight  hemor- 


PUNCTURED    WOUNDS.  I  5  I 

rhage,  limited  destruction  of  tissue,  and  the  frequency  with  which 
the  foreign  bod\'  that  made  the  wound  breaks  off  and  remains  in 
the  tissues.  Tlie  tissues  through  which  the  penetrating  substance 
passes  are  seldom  cut  or  torn  to  any  considerable  extent,  as  they 
yield  to  the  advancing  body,  creating  space  by  temporary  displace- 
ment. After  the  extraction  of  the  foreign  substance  the  tissues  re- 
sume their  former  normal  relations,  and  the  wound  becomes  closed, 
or  nearly  so,  the  line  of  puncture  and  its  immediate  vicinity  being 
infiltrated  more  or  less  with  extravasated  blood.  Vessels  and 
nerves  are  seldom  injured  sufficiently  by  the  penetrating  body  to 
require  special  interference.  The  surgeon  takes  advantage  of  this 
well-known  clinical  fact,  and  in  important  localities,  where  deep 
abscesses  are  to  be  opened  or  counteropenings  must  be  made, 
resorts  to  tunneling  of  the  tissues  with  a  pair  of  locked  hemostatic 
forceps  rather  than  to  the  free  use  of  the  knife,  as  he  knows  that  by 
puncturing  the  tissues  in  this  manner  important  vessels  and  nerves 
will  escape  injury.  Punctured  wounds  often  lead  to  tetanus  when 
the  implement  with  which  the  puncture  is  made  carries  with  it  dirt, 
and,  what  it  so  often  contains,  the  bacillus  of  tetanus.  Punctured 
wounds  of  the  skull  and  of  any  of  the  large  joints  are  often  fol- 
lowed by  the  most  disastrous  inflammatory  complications,  owing 
to  the  difficulties  encountered  in  attempts  at  primary  disinfection. 
Large  punctured  wounds  very  often  heal  promptly  and  with  very 
little  functional  impairment.  A  case  is  now  under  my  obser- 
vation in  which  the  base  of  the  thigh  was  completely  transfixed 
by  a  buggy  shaft.  The  metallic  point  of  the  shaft  entered  the 
inner  surface  of  the  thigh,  passed  between  the  femoral  artery 
and  the  femur,  outward,  forward,  and  upward,  and  made  its  e.xit 
below  Poupart's  ligament,  about  two  inches  below  the  anterior 
superior  spinous  process  of  the  ilium.  The  accident  was  sustained 
in  a  runaway,  and  the  force  was  so  great  that  the  shaft  broke  two 
or  three  feet  from  its  end,  requiring  considerable  force  to  extract 
the  foreign  body,  which  completely  transfixed  the  thigh.  Hemor- 
rhage was  very  slight,  but  the  shock  was  severe.  The  surfaces 
of  the  wounds  of  entrance  and  exit  were  disinfected,  and  the 
wounds  freely  dusted  with  borosalicylic  acid,  and  the  usual  dry 
antiseptic  dressing  applied.  No  attempt  was  made  to  disinfect  the 
large  tubular  wound.  Very  little  temperature,  swelling,  and  pain 
followed  the  accident.  Both  wounds  healed  under  one  dressing, 
and  although  the  muscles  were  badly  lacerated,  the  functional 
result  was  almost  perfect,  notwithstanding  the  man  was  nearly 
sixty  years  of  age  and  quite  obese. 

In  the  treatment  of  punctured  wounds  the  first  indication  that 
presents  itself  is  to  look  for  the  foreign  substance  that  made  the 
puncture,  and  which  so  often  remains  in  the  tissues.  If  found,  it 
is  of  course  to  be  extracted.  Metallic  substances  and  glass  can 
be  accurately  located  by  the  X-ray.  Needle-points,  splinters  of 
wood,  and  gla.ss,  if  near  the  surface,  can  be  located  by  digital  pal- 


152 


WOUNDS. 


pation,  and  if  this  can  not  be  done,  the  tenderness  on  pressure 
serves  as  a  valuable  guide  in  locating  and  removing  them.  If  in- 
fection follows  a  punctured  wound,  early  incision  and  drainage  be- 
come necessary  to  prevent  the  formation  of  a  diffuse  abscess.  Very 
frequently  when  this  occurs  a  foreign  substance  that  was  not  sus- 
pected, much  less  sought  for,  is  discovered  in  the  abscess. 

6.  Gunshot  wounds  will  receive  separate  consideration  else- 
where, but  in  this  connection  it  must  be  said  that  they  differ  mate- 
rially from  lacerated,  contused,  stab,  and  punctured  wounds  ana- 
tomically, as  well  as  from  a  practical  standpoint.  The  bullet,  which 
travels  with  much  greater  force  and  velocity  than  the  implements 
that  inflict  the  wounds  we  have  already  described,  carries  before  it 
all  the  tissues,  including  bone,  producing  a  tubular  wound,  sur- 
rounded by  a  zone  of  contused  tissue.  The  small-caliber  jacketed 
bullet  causes  less  contusion  than  the  old-fashioned  round  or  conic 
ball  of  lead.  The  wound  of  exit  is  usually  larger  and  more  ragged 
than  the  wound  of  entrance.  Tlie  modern  bullet  makes  a  straight 
wound ;  deflection  seldom  takes  place,  and  ivlien  it  does  occur,  it  is  at 
great  range.  A  bidlet  ivound  shoidd  never  be  probed,  either  for  diag- 
nostic or  tlierapentic  pitrposes.  In  the  light  of  modern  surgery  bidlet 
wounds  have  become  a  noli  me  tangere  to  the  surgeon.  In  recent 
cases  operative  interference  becomes  necessary  in  case  of  profuse 
hemorrhage  only,  or  when  complicating  visceral  lesions  demand  it. 
The  best  results  are  obtained  when  the  surgeon  concentrates  his 
energies  and  skill  in  protecting  the  wound  against  infection  by  an 
efficient  first-aid  dressing. 

7.  Poisoned  wounds  are  classified  separately  from  punctured 
wounds,  not  because  they  differ  from  them  in  their  appearance  and 
the  manner  in  which  they  are  inflicted,  but  because  they  become 
dangerous  to  life  by  the  insertion  into  the  wound  of  a  preformed 
poison  with  the  vulnerating  body.  Dissection  wounds,  the  stings 
of  poisonous  insects,  and  the  bites  of  venomous  snakes,  reptiles, 
and  rabid  animals  furnish  familiar  instances  of  what  is  understood 
by  poisoned  wounds.  The  injury  in  itself  is  usually  insignificant ; 
the  danger  lies  in  the  introduction  into  the  wound  of  the  preformed 
poison.  Antiseptic  measures,  employed  with  the  intention  of 
guarding  against  infection  of  any  other  kind  of  wound,  are  of 
no  value  in  the  treatment  of  such  cases.  In  poisoned  wounds  the 
surgeon  directs  his  first  attention  to  the  extraction  or  neutralization 
of  the  specific  poison,  and  by  mechanical  measures  to  guard  against 
its  absorption  into  the  general  circulation.  Circular  constriction  on 
the  proximal  side  is  made  to  prevent  absorption  ;  the  wound  and 
its  contents  are  excised  to  effect  mechanical  removal  of  the  poison, 
or  the  wound  is  cauterized,  or,  finally,  chemic  agents  are  employed 
locally  to  neutralize  the  poison  or  to  render  it  harmless.  In  the 
case  of  bites  from  rabid  animals  Pasteur's  prophylactic  treatment 
is  the  one  that  has  been  found  most  reliable  in  preventing  the 
reproduction  of  the  disease  in  man,  as  well  as  in  animals. 


REPAIR    OF    WOUNDS. 


153 


Fig.  89. 


-Forms  assumed  in  indirect  cell-division  (Green, 
from  Flemming). 


REPAIR  OF  WOUNDS. 

As  immediate  union  of  wounds  never  takes  place  in  any  part 
or  tissue  of  the  body,  we  are  prepared  to  assume  and  prove  that 
every  wound  heals 
by  the  interposi- 
tion between  the 
divided  parts  of  a 
greater  or  smaller 
amount  of  new  tis- 
sue. The  new  cells 
which  fill  in  the 
gap  are  derived 
from  the  preexist- 
ing cells  from  the 
s  u  r  face  of  the 
wound  and  its  im- 
mediate vicinity  by 
a  process  of  indi- 
rect cell-division  recently  described  as  karyokinesis  (Figs.  89  and  90). 
In  vascular  tissue,  repair  of  a  wound  means  union  between  the 
divided  tissues  of  similar  anatomic  structures,  and  restoration  of  the 

interrupted  circula- 
tion by  the  forma- 
tion of  new  collat- 
eral blood-vessels. 
If  the  wound  re- 
mains aseptic  and 
the  surfaces  of  the 
wound  are  kept 
in  accurate  coapta- 
tion, the  healing  is 
accomplished  in  a 
short  time  and  by 
the  production  of 
a  minimum  amount 
of  new  tissue.  A 
similar  wound,  with 
great  loss  of  tissue, 
precluding  the  pos- 
sibility of  bringing 
the  parts  in  apposi- 
tion by  mechanical 
measures,  must 
necessarily  heal  by 
the  formation  of  a 
large  amount  of  granulation  tissue,  the  process  of  repair  in  both 
instances  being  the  same,  the  difference  being  mainly  in  the  length 


c^%^-' 


WAsmm 


Fig.  90. — Process  of  repair  of  a  wound  :  a,  ti,  Cells 
forming  connective  tissue  ;  i>,  l>,  h,  leukocytes  ;  c,  newly 
formed  blood-vessels  (Keen  and  White). 


154 


WOUNDS. 


of  time  required  to  complete  the  healing  process  and  the  quantity 
of  new  material  necessary  for  this  purpose  (Fig.  91).  In  both  in- 
stances it  may  be  said  that  the  wound  healed  by  primary  intention. 
Healing  by  primary  intention  takes  place  in  all  wounds  in  which  all 
the  new  material  produced  is  utilized  in  the  process  of  repair. 

Primary  union  means  an  uninterrupted  process  of  construction 
from  the  time  the  wound  is  inflicted  until  it  is  completely  repaired, 
regardless  of  time  and  the  amount  of  new  material  required  to 
restore  the  interrupted  continuity.  If  the  wound  can  be  sutured 
throughout  and  heals  by  primary  intention,  it  does  so  without 
visible  granulation  tissue.  If  the  wound  can  not  be  closed,  owing 
to  loss  of  substance  or  other  conditions  contraindicating  approxi- 
mation of  its  margins,  the  defect  or  gaping  part  of  the  wound 
becomes  covered  with  visible  granulations  before  it  can  heal.  The 
best  functional  and  cosmetic  results  are  obtained  in  aseptic  wounds 
that  admit  of  suturing  throughout  and  that  heal  by  primary  inten- 
tion.    Ideal  wound  healing  consists  in  restoration  of  the  continuity  of 


Fig.  91. — Wound  healing  by  granulation  (Keen  and  White). 

all  the  anatomic  stnictures  severed,  by  the  interposition  of  a  minimum 
amo7int  of  nezv  tissue,  and  by  return  of  function  ad  integrum. 

This  description  of  what  should  be  aimed  at  in  the  treatment  of 
a  recent  wound  intimates  what  is  required  of  the  surgeon  when  he 
undertakes  to  assist  nature's  resources  in  accomplishing  so  perfect 
a  result.  The  surgeon's  duty  is  clear  :  he  must  secure  and  main- 
tain asepsis  ;  he  must  unite  by  mechanical  measures  the  same  kind 
of  tissues  by  careful  suturing  ;  he  must  secure  perfect  hemostasis 
before  closing  the  wound,  and,  finally,  during  the  time  required  for 
the  healing  of  the  wound  he  must  place  the  injured  part  in  a  con- 
dition approaching  as  nearly  as  possible  absolute  physiologic  rest. 
The  surgeon  must  not  forget  that  each  tissue  furnishes  its  own  mate- 
rial in  the  ideal  repair  of  a  wound,  and  that  substitution  of  a  material 
from  other  tissues  necessarily  yields  fatilty  functional  residts.  It  is 
of  the  utmost  importance  to  unite  by  careful  suturing,  which  often 
implies  the  use  of  the  absorbable  buried  suture,  nerve  to  nerve, 
tendon  to  tendon,  muscle  to  muscle,  bone  to  bone,  periosteum  ^--^ 


Plate  i. 


\ 


■^ 


U-ft  margin  of  womul  healing  by  first  iuU-nium  on  ll.e  ihinl  day  :  „,  I'-pKlernuc  layer, 
showing  cells  umlerKoin«  karyokineMs  ;  /-,  l.-ukocytes  a«:umulati.,«  on  the  edfie  ..I  the 
wound;  r,  hl.HKl-clol  filling  dead  space-commencing  "  orf;ani/ali..n  "  ;  </,  vein  trom 
wbJ'  li  leukocytes  are  eniijjratinK, 


REPAIR    OF    WOUNDS.  155 

periosteum,  fascia  to  fascia,  mucous  membrane  to  mucous  mem- 
brane, peritoneum  to  peritoneum,  and  skin  to  skin.  Too  much 
stress  can  not  be  placed  on  the  most  pedantic  manner  in  which  a 
recent  wound  should  be  sutured.  Care  and  time  spent  in  this 
part  of  the  treatment  are  always  well  repaid.  Some  of  the  most 
brilliant  operators  are  neglectful  of  this  part  of  their  work.  The 
most  successful  surgeon  is  the  one  who  not  only  knows  how  to 
make  wounds,  but  who  appreciates  the  importance  of  aiding  the 
process  of  repair  by  careful  suturing. 

The  macroscopic  and  microscopic  appearances  of  granulating  sur- 
faces are  nearly  identical  in  all  the  tissues.  A  denuded  bone  covered 
with  granulations  presents  a  similar  appearance  to  a  granulating  sur- 
face of  an}'  of  the  soft  tissues.  Even  the  embryonic  cells  of  which 
the  granulations  are  composed,  as  long  as  they  remain  in  this  state, 
furnish,  from  their  microscopic  appearance,  no  indications,  or  only 
remote  ones,  as  to  their  histogenetic  source  and  ultimate  physiologic 
destination.  Differentiation  takes  place  during  their  further  de- 
velopment toward  the  completion  of  the  healing  process.  The 
bulk  of  all  granulation  tissue  is  derived  from  the  connective  tissue, 
as  this  mesoblastic  structure  is  diffused  throughout  the  entire  body 
and,  with  the  exception  of  the  central  nervous  system,  is  found  in 
almost  every  organ.  In  the  nervous  system  it  is  represented  by  an 
almost  similar  tissue, — the  neuroglia, — which  performs  the  same 
role  in  repair  of  injuries  and  defects  of  the  brain  and  spinal  cord. 
A  wound  or  defect  covered  with  granulations  presents  a  velvety 
appearance,  each  tuft  or  papilla  representing  a  separate  loop  or 
network  of  new  capillaries.  The  new  capillaries  spring,  in  the 
form  of  buds,  from  existing  capillaries  near  the  surface  of  the  wound, 
and  form  connections  with  similar  loops  on  the  opposite  side  during 
the  healing  process,  in  this  maimer  reestablishing  the  vascular 
connections  between  the  two  wound  surfaces.  In  wounds  that 
heal  rapidly  the  existence  of  most  of  the  new  blood-vessels  is  a 
short  one.  With  the  beginning  of  cicatrization  they  disappear 
rapidly,  and  comparative!}'  few  of  them  remain  as  permanent  struc- 
tures as  a  .system  of  collateral  vessels  that  restore  indirectly  the 
loss  of  continuity  between  the  divided  vessels. 

Prompt  avascularization  of  the  scar  is  one  of  the  best  indications 
that  the  process  of  healing  has  terminated  in  a  satisfactory  maimer. 
The  transformation  of  embryonic  into  permanent  fixed  tissue-cells 
is  known  as  cicatrization.  In  tissues  endowed  with  great  vegetative 
powers  and  a  high  degree  of  physiologic  adaptation  even  large 
defects  are  replaced  by  tissue  that  resembles  to  perfection — ana- 
tomically, histologically,  and  physiologically  —  the  injured  pre- 
existing tissue.  This  is  the  case  in  injuries  involving  considerable 
loss  of  substance  in  bone,  tendons,  and  peripheral  nerves.  In  other 
ti.ssues  endowed  with  less  reparative  energy — as,  for  instance,  the 
muscular  fiber — a  slight  separation  results  in  the  formation  of  cica- 
tricial tissue  between  the  anatomic  structure  which  it  is  the  intention 


1 56  WOUNDS. 

to  unite.  By  cicatrization,  therefore,  is  understood  the  completion  of 
the  healing  process,  the  term  not  necessarily  implying  the  formation  of 
a  pernianent  scar.  The  ideal  healing  of  a  wound  cidniinates  in  the 
fojnnation  of  a  union  which  effects  a  physiologic  restitution  of  the  iji- 
jured part.  As  a  rule,  it  can  be  stated  that  the  result  will  be  satis- 
factory in  a  reverse  ratio  to  the  amount  of  granulation  tissue  pro- 
duced or  required  in  the  process  of  repair.  A  wound  of  the  ex- 
ternal surface  of  the  body  can  be  said  to  have  healed  after  the  com- 
pletion of  epidermization.  In  accordance  with  the  general  law  of 
succession  of  cells,  epidermization  takes  place  exclusively  by  pro- 
liferation of  preformed  epithelial  cells,  and  consequently  the  process 
begins  at  the  margins  of  the  skin  and  spreads  continuously  over  the 
granulating  surface.  It  appears  first  as  a  delicate,  bluish-pink  pel- 
licle. New  epithelial  cells  possess  ameboid  movements,  and  when 
detached  from  the  epithelial  matrix,  may  wander  some  distance  and 
form  permanent  attachments,  in  such  an  event  an  independent 
center  of  epidermization  being  established.  The  irregular  projections 
of  the  new  skin  over  the  granulations,  so  frequently  observed  during 
the  healing  of  wounds  by  granulation,  are  undoubtedly  often  due  to 
such  -migration  of  epithelial  cells.  The  granulations  in  the  imme- 
diate vicinity  of  the  zone  of  epidermization  become  reduced  in  size, 
the  blood-vessels  become  smaller  and  are  fewer  in  number,  and  the 
underlying  fibroblasts  are  rapidly  converted  into  connective  tissue. 
In  wounds  healing  by  open  granulations  new  papillse  are  formed  in 
the  new  skin,  because  the  capillary  loops  atrophy  downward  and 
become  the  papillary  vessels. 

Union  by  secondary  intention  takes  place  in  wounds  in  which 
suppuration  precedes  the  process  of  repair.  In  a  suppurating 
wound  the  embryonic  cells  that  are  destined  to  become  trans- 
formed into  new  tissue  are  exposed  to  the  destructive  action  of  pus- 
microbes  and  their  toxins,  their  protoplasm  is  destroyed,  and  they 
become  one  of  the  biologic  sources  of  pus-corpuscles.  The  cells 
on  the  surface  of  the  wound,  being  most  distant  from  the  vascular 
supply,  possess  the  least  power  of  resistance  to  the  action  of 
pyogenic  microbes,  and  on  this  account,  as  well  as  from  the  greater 
number  of  pus-microbes  on  the  surface  of  the  wound  than  in  the 
deeper  tissues,  they  are  converted  into  pus-corpuscles.  As  long  as 
suppuration  remains  active  the  superficial  layer  of  granulation  cells 
is  destroyed,  and  as  soon  as  other  embryonic  cells  take  their  place, 
the  process  is  repeated  ;  thus  the  healing  of  the  wound  is  indefi- 
nitely delayed.  When  a  favorable  change  takes  place  in  the 
wound,  either  spontaneously  or  from  the  employment  of  antiseptic 
measures,  suppuration  is  diminished,  the  granulations  become 
firmer  and  more  vascular,  and  cicatrization  and  epidermization  now 
progress  in  a  satisfactory  manner  and  terminate  in  healing  of  the 
wound  by  secondary  intention.  So  favorable  a  change  in  the  con- 
dition of  the  Avound  can  readily  be  accounted  for  by  the  employ- 
ment of  such  agents  as  are  known  to  destroy  the  microbic  cause 


WOUND    INFECTION.  I  57 

of  the  suppuration  when  brought  in  contact  with  the  wound.  In 
such  a  case  we  would  naturally  expect  that  with  the  removal, 
destruction,  or  rendering  inert  of  the  pus-microbes  the  embryonic 
cells  would  remain  attached  to  the  point  where  they  were  pro- 
duced, and  would  soon  be  converted  into  tissue  resembling  the 
matrix  that  produced  them.  Spontaneous  cessation  of  suppuration, 
and  with  it  the  conversion  of  a  surface  covered  with  dead  material 
mto  a  healthy  granulating  surface,  would  indicate  that  the  viru- 
lence of  the  pus-microbes  had  become  diminished,  that  the  soil  was 
no  longer  congenial  for  their  reproduction,  or,  finally,  that  the 
resistance  on  the  part  of  the  tissues  to  their  pathogenic  action  had 
become  increased.  That  tissue  resistance  has  a  potent  influence  in 
neutralizing  and  modifying  the  toxic  action  of  micro-organisms  has 
been  observed  clinically  and  demonstrated  experimentally.  Besides 
the  important  matter  of  time  and  the  dangers  incident  to  suppura- 
tion, wounds  that  heal  by  secondar}-  intention  as  a  rule  leave  a 
larger  scar,  and  the  functional  results  are  less  satisfactor}^  than 
those  following  healing  by  primary  intention.  The  surgeon  must 
exercise  his  skill  and  focus  his  attention  on  meeting  the  indications 
presented  by  the  infection  before  he  can  render  efficient  service  in 
aiding  the  process  of  repair.  After  suppuration  has  abated,  much 
can  be  done  in  expediting  the  healing  process  by  secondary  sutur- 
ing, position,  and  the  use  of  strips  of  adhesive  plaster  over  a  small 
aseptic  dressing  with  a  view  to  approximating  the  margins  of  the 
wound.  The  cases  best  adapted  for  secondary  suturing  are  those 
in  which  suppuration  has  ceased  and  the  granulations  have  become 
small  and  firm — in  short,  wounds  in  which  cicatrization  has  com- 
menced. 

WOUND  INFECTION. 

The  mystery  of  wound  infection  was  cleared  up  by  the  discovery 
of  the  essential  microbic  cause.  Bacteriology,  one  of  the  most  recent 
and  progressive  of  modern  sciences,  has  demonstrated  most  con- 
clusively that  all  inflammatory  wound  complications  are  caused  by 
the  presence  of  pathogenic  micro-organisms.  As  in  the  case  of 
nearly  all  infectious  diseases,  years  before  the  specific  pus-microbes 
were  discovered  living  organisms  were  found  in  pus  and  were 
described  and  believed  to  be  the  essential  cause  of  suppuration.  In 
1865  Klcbs  discovered,  in  the  tubuli  uriniferi  in  cases  of  pyelo- 
nephritis following  suppurative  cystitis,  between  the  pus-cells,  small, 
round  cocci  which  he  believed  produced  the  infection.  In  1872  the 
same  author  published  the  results  of  his  researches  on  septic  wound 
diseases  during  the  Franco-Prussian  war.  In  this  work  he  again 
referred  to  the  micro-organisms  that  he  had  j^reviously  described, 
and  showed  that  they  existed  in  the  tissues  and  organs  the  scat 
of  suppurative  inflammation  before  pus  had  formed.  He  also 
showed  how  the.sc  micro-organisms  enter  the  circulation  and  become 
the  direct  cause  of  di.stant  infective  processes.      Fven  at  that  time 


158 


WOUNDS. 


he  insisted  that  as  long  as  the  cocci  remained  only  in  the  tissues  at 
the  point  of  infection,  they  produce  only  local  inflammation  or 
necrosis,  but  as  soon  as  they  enter  the  general  circulation  fever  and 
other  symptoms  of  septic  infection  arise. 

A.  Ogston,  the  discoverer  of  pus-microbes,  published  the  result 
of  his  researches  in  1881.     This  patient  investigator  examined  the 


Fig.  92. — Streptococcus  pyogenes  (Jakob). 


Fig.  93. — Gonococci  in  leukocytes  ;  cover- 
glass  preparation  of  gonorrheal  pus. 


pus  of  69  abscesses  for  micro-organisms,  and  found  in  17  of  them 
a  chain  coccus  (streptococcus)  ;  in  31  cocci  that  arranged  them- 
selves in  groups  that  resemble  a  grape  (staphylococcus),  and  in  16 
both  of  these  forms  were  present.  In  cold  abscesses  he  failed  to 
find  either  of  these  micro-organisms.  He  also  ascertained  that 
these  two  kinds  of  microbes  differed  in  their  manner  of  diffusion 


QQ 


Fig.  94. — Diagram  illustrating  the  morphology  of  the  cocci :  a.  Coccus  or  micro- 
coccus ;  b,  diplococcus  ;  c,  d,  streptococci  ;  e,  f,  tetracocci  or  merismopedia  ;  g,  h,  modes 
of  division  of  cocci ;  i,  sarcinse  ;  j,  coccus  with  flagella  ;  k,  staphylococci  (McFarland). 

in,  and  action  on,  the  tissues,  as  the  streptococcus,  following  the 
lymph-channels  and  connective -tissue  spaces,  was  seen  to  be  the 
cause  of  diffuse  suppurative  processes,  while  the  staphylococcus 
was  found  by  him  only  in  the  pus  of  circumscribed  abscesses,  an 
observation  fully  confirmed  by  subsequent  observations. 

Julius  Rosenbach  took  up  the  work  where  Ogston  left  it,  and  as 


WOUND    INFECTION.  I  59 

the  fruit  of  a  number  of  years  of  patient  study  and  research  pub- 
Hshed  his  classic  work  in  1884  ("  Micro-organismen  bei  den  Wund- 
infections-Krankheiten  des  Menschen  ").  Rosenbach's  work  has 
served  as  a  basis  for  all  researches  on  suppurative  inflammation 
since  that  time.  Rosenbach  availed  himself  of  the  advantages 
offered  by  the  improved  technic  of  bacteriologic  work  founded  by 
Robert  Koch,  as  he  cultivated  the  different  pus-microbes  upon  solid 
nutrient  media,  and  pointed  out  the  difference  in  the  macroscopic 
appearances  of  the  cultures  of  the  different  kinds  of  pus-microbes, 
which  enabled  him  to  differentiate  between  them  without  the  use 
of  the  microscope.  He  discovered  the  staphylococcus  pyogenes 
aureus,  the  micrococcus  pyogenes  tenuis,  and  three  kinds  of  bacil- 
lus saprogenes. 

Passet  should  be  mentioned  next  in  the  long  list  of  distinguished 
names  of  original  investigators  who  have  made  the  bacteriology  of 
infection  and  suppuration  an  object  of  special  study.      He  discovered 
and  described  the  staphylococcus  citreus,  the 
staphylococcus  cereus  albus,  and  the  staphylo-  v      ^/ —      9 

coccus  cereus  flavus,   and   from   a    perirectal        **~~-         ^y^  — \ 
abscess    he  cultivated   the   bacillus  pyogenes  </~^  —    » 

fcetidus.      The   bacillus   pvocyaneus   was    de-  tt-        -       r.    -u 

■u   ^    u      n  A  ^  r\         ■  Ti  ^'S-    95— Bacillus 

scribed  by  Gessard  and  Lharrin.      Ine  gono-     tetani ;   cover-glass  pre- 

coccus,  the  specific  microbe  of  gonorrhea,  was     paration  from  culture  by 
discovered  by  Neisser  in  1879.     Fehleisen  dis- 
covered   the    streptococcus    of    erysipelas    in  ^^^ 
1883.     The  identity  of  the  garden-earth  bacil-          ^'^  V^!. 
lus  discovered  by  Nicolaier  with  the  bacillus         /^  ,s^, 
of  tetanus  was  demonstrated  in  Koch's  labo- 
ratory, April  10,  1887,  and  in  1889   Kitasato            ^'g-   96. —Bacillus 
succeeded    in    obtaining    a    pure    culture    by     f/iiic^Je^)"*^"^ 
exposing  the  inoculated  nutrient  medium  to 

hydrogen  gas  instead  of  to  atmospheric  air.  The  bacillus  coli 
commune,  discovered  by  Emmerich  in  1885  and  so  constantly 
found  in  the  intestinal  canal,  has  been  detected  so  often  in  abscesses 
as  the  sole  micrf)bic  cause  of  suppuration  that  it  deserves  classifica- 
tion with  the  pus-microbes.  The  pyogenic  effect  of  the  streptococ- 
cus of  erysipelas  is  doubted  by  many,  as  it  is  well  known  that 
uncomplicated  erysipelatous  inflammation  seldom,  if  ever,  termi- 
nates in  suppuration.  The  bacillus  and  diplococcus  of  pneumonia 
under  certain  circumstances  may  give  rise  to  suppurative  inflannna- 
tion  and  abscess  formation,  as  both  of  these  microbes  have  been 
found  in  the  pus  of  abscesses  in  different  organs  and  parts  of  the 
body.  Councilman  proved  by  his  exi)eriments  that  certain  chemic 
substances — metallic  mercury,  turpentine,  and  croton  oil — produce 
suppuration.  Abscesses  caused  in  this  manner  are  circumscribed 
and  their  contents  are  .sterile,  and  if  injected  into  living  tissue,  the 
result  is  always  negative.  It  has  also  been  demijustrated  by 
Grawitz   and   de  Bary  that  the  toxins   derived   from   the   different 


l6o  WOUNDS. 

kinds  of  microbes  produce  a  similar  effect,  and  it  is  probable  that 
the  pus-microbes  are  less  concerned  in  the  destruction  of  cell  proto- 
plasm than  their  product,  the  toxins. 

The  etiologic  relation  of  pus-microbes  to  infection  and  suppu- 
ration has  been  well  established  by  experimentation  and  clinical 
observations.  Experiment  has  shown  that  some  form  of  pus- 
microbes  is  always  found  in  the  pus  of  acute  abscesses  ;  all  the 
microbes  which  have  been  mentioned  as  possessing  specific  pyogenic 
properties  have  been  cultivated  upon  artificial  nutrient  media,  and 
the  cultures  injected  into  the  tissues  of  animals  susceptible  to  pyo- 
genic infection  have  produced  suppurative  inflammation.  It  is  seen, 
therefore,  that  all  requirements  set  down  by  Koch  in  establishing 
the  causative  relation  between  a  certain  microbe  and  a  definite  dis- 
ease have  been  fully  met.  Clinically  we  know  that  intentional 
wounds  heal  by  primary  intention  if  the  necessary  preparations  are 
made  and  directed  toward  preventing  the  entrance  of  pathogenic 
microbes  into  the  wound.  The  surgeon  must  recognize  the  well- 
established  fact  that  infection  and  suppuration  practically  never 
occur  without  pus-microbes.  No  kind  or  amount  of  injury  can  give 
rise  to  suppuration  independently  of  the  essential  microbic  cause  of 
infection.  It  is  plain  that  the  surgeon's  daily  work  consists  largely 
in  a  constant  warfare  against  microbes.  The  prevention  of  wound 
infection  is  his  daily  occupation.  If  he  is  successful  in  this  part  of 
his  undertaking,  the  hardest  battle  has  been  fought :  the  wounded 
are  safe  in  his  hands,  and  his  operative  work  becomes  a  source  of 
pleasure  and  gratification  to  him  and  a  blessing  to  his  patients. 

Pus-microbes,  the  essential  cause  of  wound  infection,  appear  to 
be  almost  omnipresent,  while  others  are  diffused  over  a  more  lim- 
ited area,  their  existence  being  dependent  upon  certain  conditions 
of  the  soil  or  temperature.  Water  as  a  medium  of  diffusion  and  as 
a  vehicle  for  the  entrance  into  the  organism  of  pathogenic  microbes 
is  of  greater  interest  to  the  physician  than  to  the  surgeon.  The 
superficial  layer  of  the  soil  contains  most  of  the  disease  germs  and 
spores,  as  they  are  deposited  upon  it  from  the  air,  and  carried  into 
it  by  water  that  contains  them,  the  soil  in  the  latter  instance  serving 
the  purpose  of  a  filtering  substance.  For  the  surgeon,  direct  infec- 
tion with  microbes  of  the  soil  has  acquired  new  interest  through 
Nicolaier's  discovery  that  the  bacillus  of  tetanus  has  here  its  natural 
habitat,  and  from  the  well-known  circumstance  that  the  bacillus  of 
anthrax  is  known  to  multiply  in  the  soil  of  pastures  that  have  been 
inhabited  by  animals  suffering  from  this  disease. 

Of  all  media  that  serve  as  carriers  of  microbes,  the  atmospheric 
air  is  the  most  important,  because  it  is  present  everywhere,  and  no 
one  can  exclude  himself  from  it.  In  a  dry  state  pathogenic  germs 
move  with  the  currents  of  air  and  attach  themselves  again  to  the  solid 
or  fluid  substances  with  which  they  come  in  contact.  Although 
most  of  the  microbes  under  ordinary  circumstances  do  not  repro- 
duce themselves  outside  of  the  body,  their  resistance  to  heat  and 


WOUND    INFECTION.  l6l 

cold,  moisture  and  dryness,  is  so  great  that  they  often  retain  their 
disease-producing  qualities  for  an  indefinite  period  of  time.  After 
their  entrance  into  the  body  and  after  meeting  with  a  proper  nutrient 
medium,  they  exert  their  specific  pathogenic  qualities.  It  is  well 
known  that  microbes  that  hav^e  been  carried  upward  by  currents  of 
air  descend  by  virtue  of  their  own  weight.  When  the  air  is  in  a 
quiescent  state,  the  lower  strata  contain  microbes  in  greater  abun- 
dance than  the  upper.  Klebs  found  that  in  the  Campagna  districts, 
near  Rome,  an  elevation  of  three  meters  afforded  perfect  immunity 
against  malaria.  Soyka  made  some  observations  on  currents  of 
air  as  vehicles  for  the  diffusion  of  microbes  in  the  laboratory  at 
Prague.  He  came  to  the  conclusion  that  very  slight  currents  con- 
vey microbes  from  the  margins  of  drying  fluids,  while  Naegeli 
asserted  that  a  current  of  considerable  force  is  necessary  to  effect 
such  transportation,  and  that  the  raising  of  the  particles  into  the 
air  by  the  current  was  greatly  influenced  by  the  force  of  adhesion  that 
exists  between  the  particles  and  the  surface  to  which  they  adhere. 
Every  surgeon  is  anxious  to  prevent  atmospheric  disturbances  in 
the  room  where  an  operation  is  to  be  performed,  and  aims  to  .secure 
quiescence  by  closing  the  windows  and  doors  some  time  before  the 
operation  is  commenced,  for  reasons  that  become  obvious  from  the 
foregoing.  For  the  same  reasons  the  operating  room  should  be 
swept  and  dusted  the  day  before,  and  the  microbes  held  in  suspen- 
sion precipitated  and  attached  to  the  floor  by  spray,  steam,  or  by 
sprinkling  the  walls,  floor,  and  ceilings  with  an  antiseptic  solution. 

While  air  is  an  important  medium  of  diffusion  of  microbes, 
wound  infection  can  not  often  be  traced  to  this  source.  Lister's 
spray,  devised  for  the  special  purpose  of  destroying  microbes  float- 
ing in  the  air  surrounding  the  field  of  operation,  has  had  its  day, 
and  is  seldom  seen  at  the  present  time.  All  substances  brought  in 
contact  with  a  recent  ivound  and  li'hich  have  not  been  rendered  sur- 
gically clean  by  sterilization  may  become  the  carriers  of  pathogenic 
microbes,  and  of  these  the  hands,  sponges,  sutures,  ligatures,  syringes, 
instruments,  and  dressings  have  been  the  most  fruitful  sources  of 
infection.  Even  if  the  surgeon  should  not  know  the  name  of  a 
single  microbe,  if  he  takes  it  for  granted  that  minute  living  plants 
that  arc  everywhere  and  attached  to  everything  are  the  essential 
cause  of  wound  complications,  he  would  naturally  seek  for  ways 
and  means  to  prevent  their  entrance  into  the  wound,  and  would 
recognize  the  necessity  of  sterilizing  ex'erything  that  is  to  be  brought 
in  contact  with  the  wound.  Fortunately,  the  intact  skin  furnishes 
almost  a  perfect  protection  against  the  entrance  of  pus-microbes 
into  the  tissues.  No  woimd  is  too  small  and  none  is  too  large  to 
serve  as  a  gateway  or  infection  atrium  for  the  entrance  of  pus- 
microbes  into  the  tissues. 

Not  all  individuals  are  equally  susceptible  to  the  pathogenic 
action  of  pus-microbes.  We  observe  the  same  difference  of  be- 
havior toward  pus-microbes  among  the  lower  animals.  The  deli- 
II 


1 62  WOUNDS. 

cate  rabbit  and  guinea-pig  respond  very  promptly  to  injections  of 
pure  cultures,  while  the  hardier  dog  and  cat  are  very  resistant  to 
pyogenic  infection.  We  recognize  in  man  a  hereditary  and  an 
acquired  susceptibility  to  the  action  of  pus-microbes.  Again,  we 
observe  a  great  difference  on  the  part  of  the  various  tissues  to 
pyogenic  infection.  Dense  vascular  tissues,  such  as  we  find  in  the 
tongue,  lips,  and  cheeks,  possess  a  maximum  intrinsic  power  of 
resistance  to  infection,  while  the  medullary  tissue  of  bones,  the 
synovial  membranes,  and  the  adipose  and  loose  connective  tissue 
are  extremely  susceptible  to  the  action  of  pyogenic  microbes. 

The  normal  mucous  membrane  of  a  healthy  bladder  is  very 
resistant  to  pus  infection,  but  the  paralyzed  bladder  is  very  easily 
infected.  The  nature  of  the  wound  plays  an  important  part  in  the 
etiology  of  infection.  It  is  more  difficult  to  infect  an  incised  than 
a  lacerated  or  contused  wound,  and  it  is  for  this  reason  that  the 
surgeon  does  as  little  tearing  as  possible  during  an  operation.  For  the 
same  reason  he  attempts,  whenever  feasible,  to  transform,  as  nearly 
as  possible,  a  lacerated  or  contused  wound  into  an  incised  wound. 
One  of  the  most  important  indirect  causes  of  infection  is  the  pri- 
mary wound  secretion,  which,  if  permitted  to  accumulate  in  the 
wound,  serves  as  a  nutrient  medium  for  the  microbes  that  may  have 
found  entrance  into  the  wound,  and  which  without  such  a  culture 
substance  might  have  remained  harmless.  It  is  for  the  purpose  of 
rendering  the  soil  barren  that  we  resort  so  frequently  to  drainage 
in  the  treatment  of  wounds  where  the  primaiy  wound  secretion  is 
apt  to  be  profuse,  or  when,  from  the  nature  or  location  of  the 
wound,  the  formation  of  a  so-called  dead  space  or  spaces  can  not 
be  avoided  by  suturing  or  other  mechanical  measures.  Wound 
infection  is  a  complicated  process,  and  the  surgeon  must  strive  not 
only  to  guard  against  the  entrance  of  the  essential  cause,  but  must 
aim  at  the  same  time  to  prevent  those  conditions  that  are  known  to 
favor  the  reproduction  of  microbes  in  the  organism,  as  few  wounds 
are  entirely  aseptic. 

Of  the  nonsuppurative  wound  infections,  erysipelas,  erysipeloid, 
and  tetanus  furnish  the  most  striking  examples.  Fehleisen  demon- 
strated the  direct  etiologic  relationship  between  the  streptococcus 
erysipelatis  and  the  nonsuppurative  acute  dermatitis  known  as  ery- 
sipelas, by  isolating  the  microbe,  by  cultivating  it  outside  of  the 
body,  and  by  reproducing  the  disease  in  animals  and  in  man  by 
inoculations  with  pure  cultures.  When  the  streptococcus  of  ery- 
sipelas finds  its  way  into  the  lymphatics  of  the  skin  through  a 
wound,  or  perhaps  a  slight  abrasion,  in  sufficient  number  and  viru- 
lence, it  produces  a  rapidly  spreading  acute  inflammation  of  the 
lymphatics  and  skin  of  short  duration.  The  streptococcus  multi- 
plies in  the  tissues  with  wonderful  rapidity,  but  its  life  is  short,  for 
it  perishes  as  speedily  as  it  was  produced.  The  lymph-channels  and 
connective  tissue  of  the  inflamed  skin  are  densely  packed  with  what 
appears   under  the  microscope  as  an  almost  pure  culture  of  the 


WOUND    INFECTION.  163 

microbe.  Wherever  the  streptococcus  finds  its  way,  an  intense  non- 
suppurative inflammation  is  the  result.  The  disease-producing 
quahties  of  the  streptococcus  are  soon  exhausted,  and  resolution 
takes  place  at  the  point  of  invasion,  while  the  disease  continues  pro- 
gressively in  the  periphery  of  the  infected  territory.  The  microbe 
is  most  virulent  in  the  tissues  of  the  skin  most  recently  affected,  and 
it  is  from  such  places  that  the  tissue  fluids  are  taken  for  inoculation 
experiments.  The  streptococcus  grows  most  luxuriantly  in  gelatin 
at  bod\--temperature.  Fehleisen  inoculated  the  ears  of  rabbits,  and 
the  first  local  signs  of  reproduction  of  the  disease  appeared  at  the 
point  of  inoculation  in  from  twelve  to  twenty-four  hours.  Inocula- 
tions for  therapeutic  purposes  in  the  treatment  of  inoperable  malig- 
nant disease  were  made,  with  similar  positive  results.  The  time 
intervening  between  the  inoculation  and  the  development  of  the  first 
general  and  local  symptoms  varied  from  fifteen  to  sixty-one  hours. 
The  results  of  these  inoculations  have  shown  that  the  period  of 
incubation  of  this  disease  is  a  short  one.  We  can  now  understand 
the  local  and  general  spread  of  erysipelas  before  the  antiseptic  era 
in  hospitals  and  communities  by  sponges,  instruments,  hands, 
clothing,  etc.,  from  wound  to  wound  and  from  patient  to  patient. 

Another  nonsuppurative  surgical  infectious  disease  that  furnishes 
convincing  proof  of  its  microbic  origin  is  tetanus.  The  key  that 
unlocked  the  microbic  nature  of  this  somewhat  strange  wound  com- 
plication was  furnished  by  Carle  and  Rattone  in  1884.  These  inves- 
tigators produced  tetanus  in  a  rabbit  by  injecting  pus  obtained  from 
a  wound  of  a  tetanus  patient.  A  year  later  Nicolaicr  discovered  a 
microbe  in  garden-earth  which,  when  injected  subcutaneously  into 
mice,  rabbits,  and  guinea-pigs,  invariabh'  caused  tetanus.  Kitasato 
isolated  the  same  microbe  from  mixed  cultures  by  cultivation  in  an 
atmosphere  of  hydrogen  gas,  and  for  the  first  time  obtained  a  pure 
culture,  which,  when  injected  into  animals  susceptible  to  tetanus, 
invariably  [)roduced  the  disease. 

Tetanus  appears  in  animals  in  twenty-four  hours  after  the  injec- 
tion of  a  pure  culture,  and  a  fatal  termination  ma)'  be  expected  under 
all  the  symptoms  characteristic  of  tetanus  in  man  in  the  course  of 
two  or  three  days.  In  tetanus  the  action  of  the  microbe  on  the 
tissues  is  entirely  different  from  that  of  erysipelas.  In  the  latter 
disease  the  streptococcus  is  always  present  in  the  tissues  affected, 
and  its  rapid  multi|)lication  in  the  body  is  an  important  element  in 
the  extension  of  the  infection.  In  tetanus  the  bacillus  does  not 
appear  to  multiply  to  any  extent  in  the  body,  but  its  presence  can 
usually  be  determined  in  the  wound  secretion  or  in  the  tissues  at 
the  point  of  inoculation.  The  tetanic  spasms  extending  in  more  or 
less  rapid  succession  to  the  different  muscular  groups,  according  to 
the  acuity  of  the  disea.se,  are  cau.sed  by  the  action  of  the  toxins  at  a 
distance  from  the  seat  of  infection,  which  find  their  way  through  the 
fluids  of  the  body  to  remote  parts.  It  is  on  this  account  that  oper- 
ative treatment  holds  out  so  little  prospect  of  arresting  the  disease, 


164  WOUNDS. 

as  even  the  amputation  of  an  entire  limb  would  not  eliminate  the  tox- 
ins that  have  invaded  the  central  nervous  system.  Any  of  the  toxins 
isolated  by  Brieger — tetanotoxin,  spasmotoxin,  and  the  muriate  of 
toxin  free  from  any  bacilli — can  produce  tetanic  convulsions  and 
death.  As  the  tetanus  bacillus  is  an  anaerobic  microbe,  it  remains 
harmless  on  the  surface  of  the  wound  and  must  enter  the  tissues 
deeply  before  it  can  exert  its  specific  pathogenic  action.  The  con- 
ditions necessary  for  the  growth  of  the  tetanus  bacillus  readily 
explain  why  tetanus  is  met  much  more  frequently  as  a  complication 
of  punctured  and  contused  than  of  incised  wounds. 

Infection  of  wounds  with  the  bacillus  of  tuberculosis  is  ex- 
tremely rare,  as  only  a  very  few  well-authenticated  cases  of  this 
kind  are  on  record.  Large  wounds  do  not  furnish  the  conditions 
necessary  for  the  localization,  growth,  and  reproduction  of  the 
tubercle  bacillus.  Tubercular  infection  is  more  likely  to  take  place 
through  slight,  neglected  abrasions  and  small  punctured  wounds. 

Prevention  of  Wound  Infection. — The  discussion  of  the  sub- 
ject of  prevention  of  wound  infection  constitutes  the  most  impor- 
tant chapter  in  any  modern  book  on  the  practice  of  surgery.  It 
is  a  subject  with  which  every  general  practitioner  should  be  per- 
fectly familiar,  as  it  furnishes  the  key  to  successful  emergency  work. 
The  different  methods  directed  toward  obtaining  asepsis  have 
undergone  great  changes,  and  no  uniformity  in  this  regard  is  found 
among  the  surgeons  of  to-day,  but  the  object  to  be  obtained  remains 
the  same — viz.,  to  secure  an  aseptic  condition  for  the  wound  and  for 
everything  which  is  brought  in  co7itact  with  it.  AlthougJi  methods 
may  vary,  the  principles  upon  which  they  are  based  are  the  same,  and 
they  are  to  the  effect  that  asepsis  can  only  be  secured  by  disinfection 
of  the  zvound  and  its  environments,  the  field  of  operation,  the  hands 
of  the  surgeon  and  assistant,  and  sterilization  of  everything  that  is 
brought  in  contact  with  the  wound — instruments,  sponges,  sutures, 
ligatures,  drains,  and  dressing  material. 


OPERATING  ROOM. 

Since  antiseptic  treatment  has  come  into  general  use,  an  im- 
mense amount  of  money  and  a  great  deal  of  genius  have  been 
expended  in  the  construction  and  equipment  of  operating  rooms  in 
all  the  large  hospitals.  Nations,  charitable  and  educational  insti- 
tutions, have  vied  with  one  another  in  taking  the  lead  in  making 
the  necessary  improvements.  Many  of  the  operating  theaters  in 
our  large  modern  hospitals  have  been  built  at  an  enormous  ex- 
pense, and  have  been  furnished  with  the  most  elaborate  facilities  for 
aseptic  work.  It  must  not  be  forgotten,  however,  that  the  earliest 
and  most  brilliant  victories  in  antiseptic  surgery  were  scored  in  old, 
infected  hospitals  and  in  old-fashioned  operating  theaters,  where 
hospital  gangrene,  erysipelas,  suppuration,  sepsis,  and  pyemia  had 
reigned  supreme  for   years.      This   was  notably  the   case   in   von 


OPERATING    ROOM.  1 65 

Nussbaum's  clinic  at  Munich.  Before  antiseptic  surgery  was  intro- 
duced, according  to  Lindpaintner  nearly  80  per  cent,  of  those  oper- 
ated upon  were  attacked  by  hospital  gangrene.  Erysipelas  was 
common.  The  most  insignificant  wounds  suppurated.  Deaths  from 
sepsis  and  p}'emia  were  of  daily  occurrence.  With  the  introduc- 
tion of  antiseptic  surger\-all  these  wound  complications  disappeared 
as  if  by  magic.  It  is  doubtful  if  the  results  obtained  by  Volkmann 
in  the  old  clinic  have  been  improved  upon  since  the  palatial  new 
clinic  has  been  erected.  A  splendid  operating  room  ivitJi  elaborate 
facilities  for  asepsis  is  desirable,  but  not  essential  to  obtain  the  best  re- 
sults. The  Rush  Medical  College  amphitheater,  with  a  capacity 
for  holding  600  students,  is  anything  but  a  modern  operating  room, 
and  yet,  notwithstanding  that  the  surgical  clinics  are  attended  by 
from  400  to  500  students,  infection  during  operations  for  aseptic 
conditions  is  the  exception,  primary  wound  healing,  the  rule.  The 
wonderful  results  that  crown  the  surgeon's  work  to-day  are  not 
due  so  much  to  the  modern  improvements  in  the  operating  room 
as  to  the  more  intelligent  and  efficient  assistance. 

The  trained  nurse  must  not  be  forgotten  when  we  come  to  in- 
vestigate the  causes  that  have  contributed  to  modern  surgical  suc- 
cess. It  is  the  trained  niirse  zvho  performs  the  most  difficult  and 
painstaking  task  zvhen  she  prepares  for  an  operation.  How  many 
operators  are  there  who  are  competent  and  willing  to  look  after  all 
the  details  necessary  to  make  adequate  preparations  for  an  important 
operation  ?  It  is  the  trained,  conscientious  mirse  of  to-day  who  fights 
more  than  one-half  of  the  battle,  and  zvho,  as  a  rule,  receives  so  little 
credit  for  her  work.  The  trained  nurse  is  to  be  found  in  every 
operating  room  at  the  present  time,  and  it  is  she  who  hands  the 
surgeon  the  faultless  knife  when  everything  is  in  readiness  to  begin 
the  operation.  Take  away  the  trained  nurse  from  the  operating  room, 
and  the  surgeon's  work  ivill  become  more  laborious,  time-consuming, 
and  less  satisfactory.  If  I  had  the  choice  of  operating  in  the  most 
elaborate  operating  theater  without  a  trained  nurse,  and  in  the 
kitchen  of  a  farmer's  house  with  one,  I  would  not  be  long  in 
deciding  in  favor  of  the  latter,  and  I  am  confident  that  the  patient 
would  be  benefited  by  the  preference.  A  long  experience  with 
assistants  and  general  practitioners  has  satisfied  me  that  they 
can  not  be  relied  upon  in  looking  after  the  many  little  details  so 
essential  in  making  preparations  for  a  major  operation.  This  part 
of  the  surgical  work  is  woman's  special  sphere.  Her  jjride  and 
satisfaction  in  the  success  of  an  operation  are  equal  to  those  of  the 
operator.  Her  knowledge  of  household  duties  prepares  her  ad- 
mirably for  such  work.  Her  keen  sense  of  duty,  her  quick  eye 
and  sensitive  ear,  her  delicate  hands  and  fingers,  and  her  apprecia- 
tion of  cleanliness  make  her  what  she  i.s — the  surgeon's  right  hand. 
It  is  fortunate  that  these  trained  nur.ses  no  longer  limit  their  life- 
work  to  large  cities.  The  time  is  not  di.stant  when  they  will  be 
found  in  every  village  and  hamlet  throughout  the  country,  where 


1 66 


WOUNDS. 


the  general  practitioner  will  be  benefited  by  their  invaluable  assis- 
tance. It  is  with  the  aid  of  the  trained  nurse  that  the  general  prac- 
titioner will  regain  the  surgical  work  that  rightfidly  belongs  to  him. 
The  modest  little  hospitals  that  are  springing  up  in  all  the  smaller 
cities,  and  which,  as  a  rule,  are  conducted  by  trained  nurses,  are 
institutions  that  can  not  fail  to  exert  their  influence  in  the  re- 
spective communities  to  stimulate  and  advance  the  surgical  work 
of  the  general  practitioner.  I  have  personal  knowledge  of  a  num- 
ber of  such  hospitals  in  which  excellent  surgical  work  is  done, 
within  proper  limits,  by  men  who  do  not  pose  as  surgeons.      Each 


Fig.  97. — Kitchen  converted  into  operating  room. 


one  of  these  institutions,  if  properly  managed,  is  a  blessing  to  the 
sick  and  injured  of  that  community  and  a  benefit  to  the  profession. 
A  plain  little  operating  room,  presided  over  by  a  trained  nurse,  will 
enable  many  physicians  to  treat  injuries  and  perform  operations  credit- 
ably that  they  woidd  hesitate  to  undertake  zvithout  such  facilities. 

Before  antiseptic  surgery  was  practised  hospitals  were  in  bad 
repute,  and  many  surgeons  preferred  to  perform  the  more  difficult 
operations  in  private  houses,  believing  that  the  hospital  air  was 
responsible  for  the  many  wound  complications.  Pirogoff  fought  in 
vain  against  hospital  gangrene  and  purulent  edema  in  the  great  hos- 


OPERATING    ROOM. 


167 


pitals  of  St.  Petersburg,  while  in  the  hovels  of  the  poor  the  results 
of  his  operations  were  much  more  satisfactor}'.  It  is  not  difficult 
to  understand  how  the  old  hospitals  at  that  time  became  breeding- 
places  for  infection.  The  congregation  of  so  many  septic  cases  and 
the  lack  of  even  ordinary  cleanliness  could  not  fail  to  infect  every 
nook  and  corner  of  the  sick-rooms.  In  most  of  the  large  hospi- 
tals at  the  present  day  there  are  at  least  two  operating  rooms,  one 
for  aseptic  and  the  other  for  septic  cases.  Such  an  arrangement  is 
most  desirable,  and  greatly  diminishes  the  responsibilit}^  of  those 
who  have  charge  of  the  operative  work.  In  hospitals  with  only  one 
operating  room  the  aseptic  cases  should  be  disposed  of  first,  and 
after  the  day's  work  the  room  must  be  subjected  to  thorough  dis- 


Fig.  98. — Modem  operating  room,  St.  Joseph's  Hospital,  Chicago. 

infection.  The  room  should  be  so  con.structcd  that  the  walls,  ceil- 
ing, floor,  and  utensils  can  be  readily  cleaned  in  a  mechanical  way. 
Everything  that  might  be  in  the  way  of  effective  cleaning  must  be 
removed  from  the  room. 

In  private  homes  a  room  is  to  be  selected  that  is  least  frequented, 
and  very  often  the  kitchen  will  recommend  itself  as  the  best  room 
for  this  purpose.  Carpets,  curtains,  pictures,  and  all  unnecessary 
furniture  mu.st  be  removed.  Ceiling,  doors,  floor,  walls,  windows 
or  blinds,  and  all  objects  in  the  room  must  be  scrubbed  thoroughly 
with  hot  soda  solution,  to  be  followed  by  scrubbing  with  a  solution 
of  corrosive  sublimate,  i  :  1000,  or  carbolic  acid  (5  percent.).       Ihe 


1 68  WOUNDS. 

air  of  the  room  must  receive  proper  attention,  especially  in  large 
cities  and  in  small,  badly  ventilated  houses.  The  microbes  developed 
upon  the  surface  of  the  earth  find  their  way  in  limited  number  into 
the  lower  strata  of  the  atmospheric  air  by  currents  of  wind  that 
carry  with  them  visible  dust.  Naegeli  showed,  a  quarter  of  a 
century  ago,  that  microbes  are  transported  through  the  air  through 
the  medium  of  dry  dust,  never  from  fluid  organic  media  in  which 
they  grow.  Dry  air  contains  more  microbes  than  moist  air,  because 
more  dust  is  suspended  in  it,  which  serves  as  a  carrier  for  the 
microbes.  Rain  carries  with  it  microbes  from  the  air  to  the  surface 
and  purifies  the  atmosphere.  Nature's  process  should  be  imitated 
in  the  operating  room.  The  microbes  floating  in  the  air  should  be 
precipitated  by  moisture  in  the  form  of  steam  or  spray  ;  by  doing 
so  the  air  is  purified  and  the  microbes  become  attached  to  the  moist 
floor,  which  should  be  kept  moist  until  the  operation  is  completed. 
For  the  cleansing  of  wall-paper  E.  Esmarch  has  recommended  rub- 
bing with  bread,  and  his  advice  is  based  on  the  results  of  carefully 
made  experiments.  Whenever  possible,  the  room  should  be  pre- 
pared the  day  before  the  operation,  after  which  windows  and  doors 
are  closed.  In  emergency  cases  this  can  not  be  done,  but  the 
atmosphere  can  be  moistened  with  steam  in  a  very  short  time  during 
and  after  the  mechanical  and  chemic  cleaning  of  the  room  and  its 
contents.  The  kitchen  table  can  be  converted  into  an  operating 
table  that  will  answer  every  purpose,  by  placing  upon  it  a  blanket 
properly  folded  and  covering  the  same  with  a  clean  sheet.  The 
kitchen  stove  does  excellent  service  in  sterilizing  everything  that  can 
be  sterilized  by  heat — wash-basins,  pans,  water,  instruments,  etc. 
Napkins  and  towels  that  are  to  be  used  during  the  operation,  and 
the  sterility  of  which  is  doubtful,  should  be  boiled  for  five  minutes  in 
soda  solution.  Sterile  water,  hot  and  cold,  and  in  sufficient  quan- 
tity, must  be  kept  in  readiness,  as  well  as  sterile  vessels  for  its  use 
during  the  operation.  I  have  entirely  abandoned  the  use  of  simple 
sterilized  water  in  surgery,  and  have  substituted  for  it  the  normal 
salt  solution,  which  can  be  easily  extemporized  by  adding  a  tea- 
spoonful  of  pure  table  salt  to  each  quart  of  sterilized  water.  An 
active,  efficient  nurse  can  prepare  any  room  in  a  few  hours  so  that 
it  will  be  safe  to  perform  any  operation,  by  making  liberal  use  of 
hot  soda  solution,  hot  water  and  potash  soap,  antiseptic  solutions, 
and  steam.  For  major  prolonged  operations  the  temperature  of 
the  room  should  be  kept  at  not  less  than  75°  F.  Warm  blankets, 
bottles  filled  with  hot  water,  or  warm  bricks  must  be  in  readiness 
to  supply  the  necessary  heat  in  operations  upon  feeble  patients,  or 
in  cases  in  which  shock  is  liable  to  set  in  as  the  immediate  effect  of 
the  operation.  A  hypodermic  syringe,  strychnin  tablets,  capsules 
of  nitrite  of  amyl,  alcoholic  stimulants,  ether,  and  chloroform  must 
be  kept  within  easy  reach  of  the  anesthetizer. ' 

A  word  in  reference  to  the  care  of  brushes,  which  are  so  useful 
in  all  attempts  at  hand  and  surface  disinfection.     Brushes  may  be 


HAND    DISINFECTION.  1 69 

used  repeatedly  and  on  different  patients  if  they  are  thoroughly  dis- 
infected and  properly  taken  care  of  after  each  operation.  None  of 
the  substitutes  proposed  for  brushes  has  ev'er  found  its  way  into 
general  favor.  Wood-fiber  and  gauze  sponges  have  been  suggested, 
but  their  efficiency  has  fallen  short  of  the  brushes.  The  surgical 
brush  should  not  be  painted  or  varnished.  The  bristles  or  vegetable 
fibers  should  be  stiff.  After  use,  the  brushes  should  be  thoroughly 
cleansed  with  hot  water  and  soap,  sterilized  by  boiling  for  one 
minute,  and  then  immersed  either  in  a  5  per  cent,  of  carbolic  acid 
or  in  a  I  :  looo  bichlorid  of  mercury  solution  ready  for  use.  Brushes 
treated  in  this  manner  are  absolutely  sterile,  and  remain  so  as  long 
as  they  are  kept  in  the  antiseptic  solution.  New  brushes  are  steril- 
ized by  exposing  them  to  live  steam  for  thirt}-  minutes,  or  by  boiling 
them  in  soda  solution  for  from  five  to  ten  minutes. 

Before  hand  disinfection  is  commenced  coats  are  laid  aside  and 
the  sleev^es  rolled  up  securely  above  the  elbows,  when  the  operator 
and  his  assistants  are  ready  for  the  operating  room.  Should  gowns 
not  be  on  hand,  clean  night-shirts  answer  as  excellent  substitutes, 
and  in  the  absence  of  such,  a  clean  sheet  may  be  wrapped  around 
the  chest  and  abdomen  and  fastened  by  safety-pins.  Towels  can 
be  used  in  the  same  manner  for  the  arms.  As  microbes  attach 
themselves  much  more  readily  to  woolen  fabric  than  to  linen  or 
calico,  the  nurse  will  always  wear  a  calico  dress  and  over  it  an 
aseptic  gown  after  she  has  made  the  necessary  preparation  for 
asepsis.  If  during  the  operation  the  hands  of  any  one  connected 
with  the  operation  become  contaminated,  they  should  be  again  dis- 
infected by  washing  in  a  strong  antiseptic  solution,  after  which  they 
should  be  immersed  for  a  few  moments  in  normal  salt  solution, 
which  must  always  be  kept  within  easy  reach  of  the  operator,  to 
be  used  whenever  the  hands  become  bloody. 

HAND  DISINFECTION. 
Ample  experience  has  demonstrated  that  infection  by  contact 
is  to  be  feared  much  more  than  infection  by  microbes  suspended  in 
the  air.  It  is  generally  conceded  that  operation  wounds  are  most 
frequently  infected  by  contact  with  the  hands  of  the  operator  or  his 
assistants.  The  risk  of  infection  increases  with  the  number  of 
assistants,  and  this  statement  applies  with  special  force  to  new  and 
inexperienced  assistants,  as  is  the  case  in  college  clinics  in  our 
country  in  which  the  assistants  serve  for  only  three  or  four  months 
at  a  time.  Since  P^berth  discovered  numerous  bacteria  in  normal 
perspiration  in  1875,  it  has  been  found  that  the  surface  of  the  body 
is  inhabited  by  a  whole  flora  of  pathogenic  microbes.  They  are 
most  numerous  upon  the  hairy  parts  of  the  skin,  in  the  folds  and 
crevices,  in  the  outlets  of  the  glandular  appendages,  and  especially 
in  the  subungual  sj)aces  of  the  fingers.  Bordini's  .statement  that 
the  people  of  each  cf;untry  and  section  of  country  may  carry  on 
their  surface  .special  varieties  of  microbes  indigenous  to  such  local- 


I/O 


WOUNDS. 


ities  is  more  real  than  imaginary  ;  and  it  is  possible  that  each  trade 
or  occupation  may  bring  with  it  microbes  of  a  special  sort.  Fiir- 
bringer  found  that  after  working  in  the  garden,  notwithstanding  that 
he  washed  his  hands  thoroughly  in  the  usual  way,  the  bacilli  of  gar- 
den-earth clung  to  his  hands  for  several  days,  and  after  working  in  the 
laboratory  for  several  days  in  making  urine  examinations,  the  micro- 
coccus ureae  could  be  demonstrated  on  the  surface  of  the  hands  a 
number  of  days  later.  The  mouth  in  a  normal  condition  swarms 
with  a  variety  of  pathogenic  microbes.  In  the  genitals  of  the 
female  Winter  found  bacteria  as  far  as  the  internal  os,  also  in  the 
upper  respiratory  tract  and  the  distal  portion  of  the  urinary  passage. 
It  is  ceitain  that  pyogenic  microbes  inhabit  the  skin  of  all  human 
beings,  regardless  of  nationality  or  geographic  location.  Welch 
discovered  a  microbe  in   the  skin,  which  he  called  staphylococcus 


Fig.  loo. — Ordinary  vegetable-fiber  hand- 
brush. 


Fig.  99. — Green  soap  in  collapsible  tube 


Fig.  loi. — Plain  steel  nail-cleaner.  Fig.  102. — Glass  brush-box  with  cover. 


epidermidis  albus,  and  which  he  believes  is  usually  the  cause  of 
stitch  abscesses. 

Careful  hand  disinfection  is  an  essential  prerequisite  to  clean 
aseptic  surgery.  The  force  of  this  statement  is  well  understood 
and  appreciated  by  every  surgeon  of  experience,  but,  from  what  is 
only  too  often  seen,  is  not  sufficiently  comprehended  by  the  mass 
of  the  profession.  I  have  more  than  once  seen  an  excuse  for  hand 
disinfection  preparatory  to  an  operation,  in  the  shape  of  washing 
the  hands  for  a  few  moments,  with  the  weddins-ringf  in  place,  in  a 
basmful  of  water  containing  a  few  drops  of  carbolic  acid,  as  the 
only  effort  to  prevent  infection  by  hand  contact.  No  amoMtt  of 
washing,  even  in  reliable  strong  antiseptic  solutions,  tvill  suffice  to  de- 
stroy the  microbes  lodged  npon  and  in  the  skin  without  a  preliminary 
mechanical  cleansing  ivith  hot  water  and  potash  soap.    The  fatty  sub- 


HAND    DISINFECTION.  I7I 

stances  that  always  cling  to  the  surface  of  the  skin  and  about  the 
orifices  of  the  outlets  of  the  gland-ducts  protect  the  microbes 
against  the  action  of  the  most  potent  antiseptic  solution.  The 
hands  of  the  surgeon  are  to  be  feared  most,  as  he  is  constantly 
engaged  in  the  handling  of  suppurating  affections.  A  careful  hand 
disinfection  is  necessary  not  only  in  aseptic  cases,  but  should  not  be 
neglected  in  pus  cases,  as  suppurating  wounds  may  become  more 
infected  by  unclean  hands.  A  suppurating  wound  may  become 
infected  with  erj'sipelas,  and  putrefactive  infection  may  complicate 
erysipelas,  and,  finally,  a  purulent  edema  may  develop,  one  of  the 
most  dangerous  forms  of  infection. 

Hand  disinfection  is  a  difficult  problem  in  surgery.  Some  sur- 
geons are  of  the  opinion  that  this  can  be  accomplished  in  a  mechan- 
ical way  by  washing  with  hot  water  and  soap  and  a  diligent  use  of 
the  brush.  Kiimmel's  experiments  have  shown  conclusively  that 
by  this  procedure  the  hands  are  not  made  sterile.  Kiimmel  and 
Fiirbringer  made  the  first  scientific  investigations  concerning  hand 
disinfection,  and  their  conclusions  hold  good  to-day.  Kummel 
found  that  if  the  hands  are  washed  and  brushed  for  five  minutes  in 
warm  water  and  potash  soap,  followed  for  two  minutes  by  scrub- 
bing either  with  chlorin  water  or  a  5  per  cent,  solution  of  carbolic 
acid,  that  the  disinfection  is  complete.  Impressions  on  gelatin  cul- 
tures of  the  fingers  thus  cleansed  remained  sterile.  The  same  result 
was  not  obtained  by  using  a  3  instead  of  a  5  per  cent,  solution  of 
carbolic  acid.  Fiirbringer  recommended  alcohol  for  the  removal  of 
fatty  material  preparatory  to  the  immersion  of  the  hands  in  the 
antiseptic  solution.      He  recommends  the  following  procedure  : 

1.  After  the  finger-nails  have  been  carefully  trimmed  and 
cleaned,  wash  the  hands  in  warm  water  with  potash  soap,  and  brush 
for  from  three  to  five  minutes. 

2.  Dry  with  sterile  towels  and  attend  to  finger-nails  once  more. 

3.  Scrub  the  hands  for  one  minute  with  80  per  cent,  alcohol, 
and  finally  immerse  in  an  antiseptic  solution. 

Alcohol  has  become  very  popular  for  hand  disinfection  every- 
where, and  the  universal  testimony  is  in  its  favor.  Some  employ 
ether  in  its  place  ;  others,  turpentine.  All  these  sub.stances  are  ex- 
cellent solvents  for  the  fatty  material,  and  prepare  the  way  for  a 
thorough  chemic  disinfection.  It  must  be  admitted,  however,  that 
the  chemic  disinfectants  play  a  subordinate  role  in  hand  disinfection, 
and  that  they  only  become  u.seful  after  a  thorough  cleansing  of  the 
hands  by  mechanical  measures.  Reliable  hand  disinfection  does  not 
depend  so  much  on  the  kind  of  antiseptic  used  as  on  the  pedantic  man- 
ner in  which  the  attempt  is  made. 

Time  is  an  important  element  in  the  preparation  of  the  hands. 
This  is  especially  so  in  emergency  work.  In  urgent  ca.ses  the  sur- 
geon frequently  hastens  the  procedure  to  an  extent  incom[)atible 
with  thorough  disinfection.  He  should,  however,  remember,  when 
urged  to  proceed  by  patient  or  bystanders,  that  it  is  inexcusable, 


1/2 


WOUNDS. 


almost  criminal,  to  touch  a  recent  wound  with  hands  that  are  not 
surgically  clean.  More  is  lost  by  hasty  action  than  by  the  delay 
caused  in  an  earnest  attempt  to  prevent  infection  by  disinfecting  the 
hands.  Dirty  hands  have  destroyed  more  lives  than  all  the  imple- 
ments of  warfare. 

The  following  method  has  been  found  very  satisfactory  in  von 
Bergmann's  clinic  and  elsewhere  : 

1.  The  hands  and  forearms  are  scrubbed  thoroughly  with  warm 
water  and  potash  soap  for  at  least  one  minute. 

2.  The  surface  is  rubbed  dry  with  aseptic  towels  or  gauze.  All 
folds  and  subungual  spaces  receive  special  attention,  a  metallic  nail- 
cleaner  being  used  for  the  latter  location. 

3.  For  another  minute  the  skin  is  rubbed  vigorously  with  a 
sterile  gauze  sponge  saturated  with  80  per  cent,  alcohol. 

4.  Scrubbing  and  irrigation  with  a  i  :  1000  solution  of  corrosive 
sublimate  completes  the  disinfection. 

In  important  operations  I  have  relied  for  several  years  on  tur- 
pentine in  preparing  the  surface  for  the  antiseptic  solution.  After 
cleansing  the  hands  and  forearms  in  the  manner  described,  the  sur- 
face is  bathed  with  turpentine  for  at  least  one  minute,  using  the 
brush  in  cleaning  the  finger-nails,  which  should  always  be  cut  short 
and  well  trimmed.  Warm  water  and  potash  soap  are  again  used  to 
remove  the  turpentine,  after  which  the  surface  is  ready  for  the  effi- 
cient use  of  the  antiseptic  solution.  As  the  antiseptic  substance 
should  be  removed  from  the  hands,  rubbing  with  pure  alcohol  and 
finally  washing  in  a  normal  salt  solution  complete  the  procedure. 
Turpentine  does  not  damage  the  skin  so  much  as  alcohol,  and 
removes  fatty  matter  more  thoroughly  than  any  other  substance,  and, 
as  experiments  have  shown,  is  a  potent  antiseptic  in  itself  The  ex- 
periments of  Lauenstein  have  demonstrated  how  difficult  it  is  to  disin- 
fect the  skin.  In  169  aseptic  operations  he  removed  a  piece  of  skin  from 
the  field  of  operation  prepared  by  different  methods  and  implanted 
it  upon  gelatin,  and  in  every  instance  the  experiment  yielded  a  positive 
result.  Perhaps  one  of  the  best  proofs  that  all  known  methods  of 
hand  disinfection  have  their  defects  is  the  present  quite  extensive 
use  of  rubber  gloves,  advocated  by  Halsted,  Mikulicz,  Fenger,  and 
other  surgeons  who  have  had  a  long  and  rich  experience  in  the 
operating  room.  It  is  easy  to  foresee  that  this  practice  will  never 
become  general,  even  in  the  clinical  amphitheaters,  to  say  nothing 
of  the  practice  of  the  general  practitioner.  The  rubber  gloves  im- 
pair the  delicate  tactile  sense  of  the  fingers,  are  expensive,  easily 
torn,  and  furnish  a  soothing  poultice  for  the  conscience  when  the 
surgeon  fails  to  prepare  his  hands  properly.  There  is  no  doubt  but 
that  future  research  and  investigations  will  succeed  in  simplifying 
hand  disinfection,  and  that  a  procedure  will  eventually  be  devised 
that  will  dispense  with  any  and  all  excuses  for  wearing  gloves  in  the 
operating  room. 

It    is    needless    to    say  that    the    hands  of   the  assistants  and 


DISINFECTION    OF    FIELD    OF    OPERATION    OR    INJURY,  1 73 

nurses  should  be  prepared  with    the    same  care  as  those  of  the 
operator. 

DISINFECTION  OF  FIELD  OF  OPERATION  OR  INJURY. 

The  methods  of  hand  disinfection  just  described  are  appHcable  for 
the  preparation  of  the  field  of  operation  or  the  seat  of  injury.  One 
ereat  advantage  is  offered  here  that  can  not  be  made  use  of  in  hand 
disinfection,  and  that  is  the  employment  of  the  razor  as  a  mechanical 
agent  for  the  removal  of  septic  material.  Next  to  soap  and  hot 
water  the  razor  is  most  important  in  disinfection  of  the  surface  of 
the  skin  preparatory  to  the  application  of  the  antiseptic  solution. 
The  razor  not  only  removes  hair,  but  also  scrapes  away  the  super- 
ficial layer  of  the  epidermis,  softened  and  macerated  by  scrubbing 
with  hot  water  and  potash  soap.  In  operations  of  choice  the  skin 
may  be  properly  prepared  for  a  more  efficient  use  of  the  razor  and 
brush  by  apph'ing  to  the  surface  to  be  prepared  a  soft-soap  poultice 
for  a  few  hours.  This  preliminary  measure  to  macerate  the  skin  is 
of  special  importance  in  preparing  the  scalp,  scrotum,  hands,  and 
feet  for  operation.  One  of  the  commonest  faults  in  preparing  the 
surface  for  operation  is  that  the  disinfection  is  not  carried  far 
enough.  For  instance,  in  the  treatment  of  compound  fractures  of 
the  skull  it  is  not  an  unusual  practice  to  limit  the  shaving  and  dis- 
infection to  the  site  of  the  wound.  ///  all  operations  on  the  skull  the 
zvliole  scalp  should  be  shaved  and  disinfected.  Women  usually  pro- 
test against  such  a  procedure,  but  when  informed  that  this  is  done 
as  much  for  cosmetic  as  for  surgical  reasons,  the  objections  are 
overcome.  Iwery  patient  can  expect  a  fair  growth  of  hair  before 
he  recovers  from  the  effects  of  the  injury  or  operation.  Disinfection 
for  an  amputation  of  the  breast  should  include  the  whole  chest  and 
the  shoulder  and  arm  on  the  side  of  the  breast  to  be  removed.  In 
abdominal  operations  the  whole  abdomen,  including  the  pubic 
region  and  the  chest  as  far  as  the  breasts,  must  be  prepared.  In 
amputations  of  the  leg,  the  leg  from  the  seat  of  injury  or  disease 
and  the  thigh  mu.st  be  shaved  and  disinfected.  In  amputations  of 
the  thigh,  the  pelvis  on  the  corresponding  side  is  included  in  the 
preparation.  In  operations  for  hernia,  the  abdomen  as  far  as  the 
umbilicus,  the  scrotum,  penis,  and  the  groin  constitute  the  field  of 
operation  requiring  disinfection. 

In  operations  of  choice  the  disinfection  should  be  made  the  day 
preceding,  and  the  field  of  operation  covered  with  a  compress 
wrung  out  of  a  hot  antiseptic  solution,  either  a  2.5  per  cent,  of  car- 
bolic acid,  or  a  I  :  lOOO  solution  of  bichlorid  of  mercury  ;  moisture 
and  heat  are  retained  by  applying  around  the  compress  a  ring  of 
absorbent  cotton  and  over  it  gutta-percha  tissue  or  waxed  paper, 
and  the  whole  held  in  place  by  a  gauze  bandage.  The  disinfection 
is  repeated  after  the  patient  is  under  the  influence  of  the  anesthetic 
and  before  he  is  placed  on  the  operating  table.  In  emergency 
operations  the  disinfection  is  done  after  the  patient  has  been  placed 


174 


WOUNDS. 


under  the  influence  of  the  anesthetic,  to  avoid  delay  and  prevent 
one  of  the  causes  of  shock.. 

Disinfection  of  mucous  surfaces  is  still  more  difficult  than  of  the 
skin.  As  a  rule,  complete  asepsis  can  not  be  secured  by  any  of  \he 
methods  in  use  at  the  present  time,  and  in  consequence  of  the  in- 
complete disinfection  we  are  generally  forced  to  abandon  all  attempts 
to  obtain  primary  union  of  the  wound  throughout.  Irrigation  of 
the  vagina  or  rectum  with  any  of  the  more  potent  antiseptic  solu- 
tions has  no  effect  whatever  on  the  bacteria,  and,  besides,  by  doing 
so  we  incur  the  immediate  risk  of  serious,  if  not  fatal,  intoxication 
by  the  rapid  absorption  from  the  mucous  surfaces  of  the  toxic 
agent  contained  in  the  solution.  In  the  disinfection  of  mucous  sur- 
faces mechanical  measures  must  be  relied  upon  in  preparing  the 
parts  for  the  operation,  followed  by  the  use  of  mild  nontoxic  solu- 
tions, such  as  Thiersch's  solution  or  a  saturated  solution  of  boric 
acid. 

STERILIZATION  OF  INSTRUMENTS. 

Aseptic  surgery  has  necessitated  a  great  change  in  the  manu- 
facture of  surgical  instruments.  All  attempts  at  ornamentation 
have  been  abandoned.  The  beautifully  carved  handles  and  blades 
that  adorn  the  pages  of  the  old  works  on  surgery  have  become 
objects  of  curiosity,  and  are  to  be  found  only  in  museums  and  in  the 
shops  of  dealers  in  antiquities.      The  modern  surgical  instruments 


Fig.  103. — Senn's  emergency  operating  case. 


are  made  as  plain  and  smooth  as  possible.  Knives  and  retractors 
are  made  of  one  piece  of  steel,  all  inches  and  crevices  being  avoided 
whenever  possible.  Scissors  and  forceps  are  made  so  that  the  two 
parts  may  be  readily  separated  and  joined  again.  Another  great 
improvement  noticeable  in  the  instruments  used  to-day  is  their 
smaller  size  and  more  delicate  construction.  The  old-fashioned 
sword-like  amputation  knife  is  seldom  seen  now,  as  any  amputation 
can  be  done  with  a  medium-sized  scalpel,  since  surgeons  have  aban- 
doned the  transfixion  methods.  Tke  best  surgeons  need  the  fewest 
instruments.  Very  few  instruments  are  required  to  perform  any 
operation,  provided  the  selection  is  made  with  care  and  the  oper- 


STERILIZATION    OF    INSTRUMENTS. 


175 


ator  is  familiar  with  their  use.  During  one  of  my  visits  to  the 
veteran  laparotomist,  Professor  Koeberle,  I  was  shown  an  instru- 
ment case  that  would  have  found  ample  room  in  any  moderate- 
sized  hip-pocket,  and  I  was  informed  that  it  contained  all  the  in- 
struments ever  needed  in  his  abdominal  work.  Tait  and  Price  per- 
form the  most  difficult  operations  with  the  contents  of  an  ordinary 
pocket-case.  The  surgeon  should,  from  the  beginning  of  his  career, 
endeavor  to  do  his  work  with  as  few  instruments  as  possible.  With 
two  knives,  a  pair  of  dissecting  forceps  and  retractors,  a  dozen  hemo- 
static forceps  and  needles,  a  pair  of  straight  and  a  pair  of  curved  scis- 
sors, a  silver  catheter,  a  chisel,  a  saw,  and  an  Esmarch's  constrictor 
most  of  the  emergency 
operations  can  be  per- 
formed. The  old-fash- 
ioned velvet-lined  instru- 
ment cases  and  pocket- 
cases  have  been  laid  aside 
and  replaced  b}'  canvas 
covers.  Handles  for 
blades  of  different  sizes 
and  many-bladed  knives 
should  not  be  used. 
Several  years  ago  I 
made  a  selection  of  in- 
struments for  emergency 
work.  The  instruments 
are  placed  in  a  canvas 
cover,  and  the  name  of 
each  instrument  is 
stamped  with  indelible 
ink  on  the  place  where 
it  belongs.  Two  canvas 
cases  go  with  each  outfit, 
so  that  they  can  be  disin- 
fected by  boiling  in  soda 
solution  and  used  alter- 
nately.   As  dust  and,  with 

it,  microbes  would  find  their  way  through  the  canvas  to  the  instru- 
ments, an  outside  leather  case  was  added  as  an  additional  protection. 
The  first  attemjjt  at  sterilization  of  instruments  consisted  in  im- 
mersing them  in  a  Sfjlution  of  carbolic  acid,  but  the  result  soon 
showed  that  this  method  was  not  reliable.  Nussbaum  boiled  them 
in  a  5  per  cent,  solution  of  carbolic  acid.  The  edge  of  cutting  in- 
struments is  seriously  damaged  by  the  carbolic  acid  in  concentrated 
solution,  and,  besides,  the  thinnest  film  of  a  grca.sy  sub.stance  pro- 
tects the  microbe  against  the  germicidal  action  of  the  acid.  Dry  heat 
and  steam  were  next  used,  but  it  was  soon  found  that  the  former 
could  not  be  relied  upon,   while  the  latter  method  damaged  the 


Fig.  104. 


-Btjcckmann's  combined  instrument  and 
dressing  sterilizer. 


176 


WOUNDS. 


instruments  by  rusting.  Steam  sterilizes  much  quicker  than  dry- 
heat,  and  exposure  of  from  fifteen  to  twenty  minutes  usually  suffices. 
The  necessary  apparatus  for  this  method  of  sterilization  is  usually 
not  in  possession  of  the  general  practitioner.  The  cheapest  and 
probably  the  most  practical  steam  sterilizer  for  the  physician's  use 
is  the  one  devised  by  Dr.  E.  Boeckmann,  of  St.  Paul.  The  great 
defect  of  sterilization  of  instruments  by  steam  is  that  the  instruments 
become  rusty  in  a  very  short  time.  The  time  required — on  an 
average  from  thirty  to  forty  minutes — also  constitutes  a  serious 
drawback  in  emergency  cases.  Steam  under  pressure  is  more  effec- 
tive than  flowing  steam.  Redard  first  recommended  compressed 
steam  for  the  sterilization  of  instruments  in  1888,  and  at  that  time 
invented  a  small  autoclave.  The  whole  procedure  consumed  forty- 
five  minutes.  The  general  practitioner  is  in  need  of  a  simpler  method. 
SteriHzation  by  boiling  suggested  itself  next.  Miquel  recommended 
glycerin  heated  to  140°  C,  and  Tripier  and  Arloing  boiled  the  in- 
struments in  olive  oil.  Gly- 
j^(^  cerin  gives  off  a  very  dis- 

agreeable odor  in  a  boil- 
ing state,  and  oil  leaves  a 
coating  of  fat  on  the  sur- 
face of  the  instruments. 

Boiling  water  is  the 
least  objectionable  and 
most  effective  medium  of 
instrument  sterilization. 
Davidsohn  proved  by  his 
experiments  that  water  at 
boiling  temperature  com- 
pletely sterilizes  the  in- 
struments in  five  minutes. 
Boiling  in  plain  water  rusts 
steel  instruments,  and  this  is  especially  the  case  if  the  instruments 
are  immersed  before  the  temperature  is  raised  to  the  boiling-point. 
It  has  been  known  for  a  long  time,  and  Davidsohn  again  recalled  the 
fact,  that  rusting  of  instruments  in  boiling  water  can  be  prevented 
by  the  addition  of  an  alkali.  Experiments  showed  that  a  i  per 
cent,  solution  of  carbonate  of  soda  is  best  adapted  for  the  steriliza- 
tion of  instruments  by  boiling.  The  addition  of  soda  intensifies 
the  disinfecting  power  of  boiling  water.  Boiling  soda  solution  is 
the  most  powerful  germ  destroyer  known  applicable  in  practice. 
Schimmelbusch  ascertained  that  ordinary  pus-microbes  are  de- 
stroyed in  two  or  three  seconds  in  boiling  soda  solution,  and  the 
spores  of  anthrax  in  two  minutes.  The  addition  of  a  tablespoon- 
ful  of  ordinary  washing  soda  to  a  quart  of  water  is  all  that  is 
required  to  obtain  the  best  solution  in  general  practice  for  the  ster- 
ilization of  instruments  by  boiling.  The  simplicity  of  this  proce- 
dure and  the  ease  with  which  it  can  be  put  in  operation  in  any 


Fig.  105. 


-Boeckmann' s  sterilizer,  showing  arrange- 
ment for  boiling  instruments. 


ASEPTIC    SPONGES. 


177 


place  have  commended  this  method  to  the  profession.  All  that  is 
required  is  a  metallic  vessel,  water,  soda,  and  fire,  all  of  which  can 
be  obtained  in  any  household.  During  the  operation  the  instru- 
ments should  be  kept  in  a  normal  salt  or  soda  solution.  After  the 
instruments  have  been  used  they  should  be  brushed  thoroughly  with 
hot  water  and  soap,  after  which  they  are  wiped  dry  with  a  sterile 
towel  or  gauze,  and,  after  wiping  them  once  more,  they  are  returned 
to  their  proper  places  in  the  aseptic  canvas  cover.  In  emergency 
cases  the  instruments  can  be  sterilized  by  boiling  in  soda  solution 
without  removing  them  from  the  canvas  cover. 

Aseptic   Sponges. — Nussbaum  has  well  said  :    "  The   disinfec- 
tion   of   hands,  instruments,  and    sponges    is   the   most  important 
thing  in   the  whole  antiseptic  treatment 
of  wounds." 

For  many  }'ears  the  surgeons  sought 
for  a  cheap  and  safe  wiping  material  for 
wounds.  Sea-sponges,  so  extensively 
used  before  antiseptic  precautions  were 
known,  have  been  regarded  with  great 
suspicion  since.  Nussbaum  did  not  en- 
tertain the  fear  of  the  sponge  to  the  same 
extent  as  most  of  his  contemporaries, 
and  had  no  hesitation  in  placing  himself 
on  record  to  that  effect.  He  believed 
tliat  infected  sponges  could  be  sterilized 
and  made  safe  by  washing  them  thor- 
oughly with  hot  water  and  potash  soap 
and  by  immersing  them  for  one  or  two 
minutes  either  in  5  per  cent,  solution  of 
carbolic  acid  or  a  i  :  1000  solution  of 
bichlorid  of  mercury.  This  favorable 
view  of  the  employment  of  sea-sponges 
in  every-day  surgical  practice  would  find 
few,  if  any,  supporters  to-day,  as  it  is 
well  known  that  the  indiscriminate  use 
of  sponges  in  different  operative  proced- 
ures is  attended  by  man)'  risks  that  can 

not  be  avoided  even  after  what  might  appear  to  us  as  thorough 
antiseptic  treatment  of  the  sponges  after  each  ojjcration.  Sea- 
sponges  have  been  discarded  to  a  great  extent,  but  they  can  not  be 
entirely  dispen.sed  with,  as  they  serve  a  most  useful  j)nr[)(xse  in 
r)perations  in  the  cavity  of  the  mouth,  resection  of  the  upj)er 
maxilla,  stajjliylorrhaphy,  partial  resection  of  the  pharj^nx,  ampu- 
tation of  the  tongue,  and  many  abdominal  and  pelvic  operations. 
Some  surgeons  have  claimed  that  disinfection  of  sea-sponges  is  an 
easy  matter.  Nussbaum  f|uoted  Kiimmel's  convictions  when  he 
expres.sed  himself  cm  this  subject,  but  extensive  clinical  experience 
has  shown  that  this  is  not  so.  Tlx^rcjugh  cleansing  and  prolonged 
12 


Fig.  106. — Jar  of  aseptic 
sponges. 


1^8  ,  WOUNDS. 

immersion  in  a  strong  antiseptic  solution  are  necessary  for  their 
sterilization.  It  is  for  this  reason  that  surgeons  have  found  it  nec- 
essary to  use  certain  sponges,  preserved  in  glass  jars  containing  the 
solution  and  bearing  a  label  indicating  the  operating  day  (Fig.  io6). 
Used  in  this  manner  the  sponges  are  thoroughly  washed  after  each 
operation,  and  remain  in  one  of  the  strong  antiseptic  solutions  for 
a  week.  Even  after  such  prolonged  immersion  anthrax  bacilli  and 
other  micro-organisms  enveloped  by  fat  have  been  found  in  an 
active  condition  in  the  sponges. 

Ordinary  commercial  formalin  affords  a  convenient  means  for 
the  complete  sterilization  of  sea-sponges.  After  the  sponges  have 
been  freed  from  foreign  matter,  washed,  and  dried  in  the  usual  way, 
they  are  to  be  placed  in  wide-mouthed  glass  jars  with  well-ground 
glass  stoppers  and  a  sufficient  quantity  of  the  formalin  poured  over 
them  to  moisten  them  thoroughly.  A  portion  of  the  fluid  settles 
in  a  layer  at  the  bottom,  while  formaldehyd  gas  and  watery 
vapor  fill  the  upper  part  of  the  jar,  penetrating  every  fiber  of  the 
sponge.  After  two  or  three  days  they  are  ready  for  use.  When 
wanted,  the  sponge  is  removed  from  the  jar  with  forceps,  to  avoid 
injury  of  the  hands,  and  well  rinsed  in  warm,  not  hot,  sterile  water 
to  remove  all  the  formalin,  which  is  injurious  to  the  tissues.  They 
should  then  be  placed  in  warm  normal  salt  solution  for  use. 
Experiments  made  by  Colonel  W.  H.  Forwood,  U.  S.  A.,  in  1892 
with  dirty  sponges  from  the  dead-house  and  kitchen  at  the  Barnes 
Hospital,  Washington,  D.  C,  proved  the  effectiveness  of  this 
method.  The  usual  laboratory  tests  showed  no  living  organism 
after  forty-eight  hours  in  formalin  solution  of  40  per  cent,  formal- 
dehyd. Six  years'  constant  use  of  sponges  prepared  in  this  way 
in  the  practice  of  Colonel  Forwood  has  given  perfect  results,  with- 
out a  single  case  of  infection  from  that  source.  The  formalin  does 
not  impair  the  hygroscopic  qualities,  neither  does  it  injure  the  tex- 
ture of  the  sponges. 

Sterilization  of  sponges  in  a  solution  of  permanganate  of 
potash,  I  :  500,  has  been  found  quite  satisfactory.  After  thorough 
cleansing  and  washing  they  are  kept  in  this  solution  for  twenty- 
four  hours,  and  are  subsequently  bleached  by  treating  them  in  a 
I  per  cent,  solution  of  sulphate  of  soda,  to  which  is  added  8  per 
cent,  of  muriatic  acid.  They  are  then  again  washed  and  kept 
ready  for  use  in  a  5  per  cent,  solution  of  carbolic  acid.  Even  after 
so  tedious  a  process  of  disinfection  Frisch  found  20  per  cent,  of  the 
sponges  prepared  by  this  method  in  Billroth's  clinic  somewhat  de- 
fective from  a  bacteriologic  standpoint.  Sponges  can  not  be  made 
sterile  by  dry  heat,  steam,  or  boiling  without  great  damage  to  their 
texture.  According  to  Schimmelbusch,  the  following  procedure  has 
yielded  the  most  satisfactory  results  :  The  sponges  of  good  quality 
are  first  carefully  cleansed,  to  rid  them  of  foreign  material  of  any 
kind,  after  which  they  are  kept  for  some  time  in  cold  water,  and  are 
occasionally  squeezed  and  kneaded.      Sponges  that  have  been  used 


ASEPTIC    SPONGES. 


179 


are  thoroughly  washed,  first  in  cold,  and  then  in  warm,  water. 
The  sponges  are  then  squeezed  diy,  placed  in  a  bag,  and  immersed 
in  a  boiling  i  per  cent,  solution  of  soda.  As  sponges  can  not  be 
boiled  without  destro}-ing  their  usefulness,  the  kettle  containing  the 
boiling  solution  is  taken  from  the  fire  shortly  before  the  sponges 
are  immersed.  After  remaining  in  the  solution  for  half  an  hour 
they  are  sterile,  and  after  being  squeezed  dry  the  soda  is  washed 
out  in  cold  sterile  water,  when  they  are  immersed  in  the  antiseptic 
solution,  where  they  remain  ready  for  use.  Before  their  use  the 
antiseptic  is  washed  out  in  cold  sterile  water.  Schimmelbusch 
found  that  sponges  containing  anthrax  bacilli  were  absolutely  sterile 
after  immersion  for  ten  minutes  in  the  hot  soda  solution. 

During  the  operation  the  blood  is  washed  out  in  warm  normal 
salt  solution  as  often  as  becomes  necessar}'.  After  the  operation 
they  are  washed  in  soda  solution  and  again  immersed  in  a  5  per 
cent,  solution  of  carbolic  acid  for  a  week.  After  use  in  septic  cases 
it  is  advisable  to  throw  them  away.      During  a  laparotomy  or  other 


Fig.  107. — Bernay's  sponge:   A,  Natural  size  ;  B,  diojiped  in  water. 

operations,  when  the  wound  is  a  deep  one,  as  in  resection  of  the 
hip-joint,  cleaning  out  of  the  axilla,  etc.,  if  sponges  are  used,  the\' 
should  be  counted  before  and  after  the  operation,  for  the  purpose  of 
guarding  against  leaving  any  of  them  in  the  wound.  The  same 
precaution  is  necessar}^  in  the  use  of  gauze  compresses  as  substi- 
tutes for  sponges. 

Sponges  have  become  a  more  important  feature  in  the  operating 
room  since  surgeons  have  abandoned  irrigation  of  recent  wounds. 
Some  form  of  sponge  is  now  relied  on  almost  exclusively  in  clean- 
ing the  wound  of  blood.  Many  substitutes  have  been  suggested 
for  the  sea-sponge  in  surgery.  All  wiping  material  used  in  place 
of  sjjonges  must  be  hygroscopic,  sterile,  and  inexpensive.  Pledgets 
and  small  compresses  of  gauze  are  u.sed  most  extensively  at  the 
present  time,  both  in  hospital  and  {private  practice.  The  gauze 
should  be  cut  evenly  into  jiieces  of  convenient  size  with  a  large 
pair  of  tailor's  scissors  ;  when  loosely  rolled  or  folded  they  bear  a 
resemblance  to   small  sponges.      As  these  gauze  wipers  are  thrown 


i8o 


WOUNDS. 


aside  as  soon  as  they  become  saturated  with  blood,  a  large  number 
must  be  kept  on  hand  in  performing  extensive  and  bloody  opera- 
tions. Dr.  Bernay,  of  St.  Louis,  uses  discs  of  aseptic  compressed 
cotton  as  substitutes  for  sponges.      The  cotton,  properly  prepared, 

is  subjected  to  several  hundred  pounds 
of  pressure,  cut  in  circular  form  with 
a  die,  and  presented  for  use  in  the 
shape  of  a  compressed  disc  about  y^ 
of  an  inch  in  thickness,  and  of  two 
sizes  : 
large 
107). 
cotton 

that  of  gauze,  ordinary  absorbent 
cotton,  or  sea-sponge.  They  absorb 
twelve  times  their  weight  of  fluid. 
These  sponges  were  used  quite  extensively  during  the  Spanish- 
American  war  and  gave  good  satisfaction.  They  recommend  them- 
selves more  particularly  for  use  in  emergency  work,  as  a  large 
number  of  them  can  be  carried  in  the  ordinary  emergency  bag. 
An  objection,  however,  presents  itself  to  their  general  use,  as  in 
wiping  wounds  cotton  fibers  are  liable  to  become  detached  and 
remain  undiscovered  in  the  wound.  As  cheaper,  but  less  satisfac- 
tory, substitutes  for  gauze  and  cotton,  moss  and  wood-wool  in  small 
gauze  bags  have  been  employed.     From  a  technical  standpoint  sea- 


B 

%!      ^^*lk^^H 

J- 

i^^H 

the  small   I  ^  inches,  and  the 

I  ^    inches,   in   diameter   (Fig. 

The  absorbing  power  of  these 

sponges  is  much  higher  than 


Fig.  108. — Gauze  sponge. 


109. — Hart's  sponge  holder. 


^ 


3 


Fig.  no. — Sims'  sponge  holder. 

Sponges  deserve  preference ;  their  great  hygroscopic  capacity,  elas- 
ticity, and  pliability  are  unexcelled.  On  the  other  hand,  asepsis  is 
more  uncertain  when  they  are  used  repeatedly.  Good  sponges  are 
expensive,  and  sponges  of  poor  quality  are  inadmissible  in  modern 
surgical  practice. 


ASEPTIC  AND  ANTISEPTIC  DRESSING  MATERIAL. 
The  modern  wound  dressing  is  intended  to  protect  the  wound 
against  infection  after  the  surgeon  has  completed  his  work.  One  of 
the  great  advantages  of  the  dressings  as  they  are  applied  to  a  recent 
wound  to-day  is  that  the  first  dressing  remains  until  the  wound  is 
healed,  thus  securing  for  the  injured  part  rest  during  the  entire  pro- 
cess of  repair.  The  old  methods  of  wound  dressing  Avith  cold- 
water  compress,  lint,  charpie,  salves,   plasters,  and  poultices   often 


ASEPTIC    AND    ANTISEPTIC    DRESSING    MATERIAL. 


I8I 


made  an  hourl\-,  and  certain!)^  a  daily,  change  necessary.    This  could 
not   fail  to  disturb  the  wound,  causing  pain,  and  often  preventing 
necessary  sleep.      The  full  import  of  the  advances  made  in  wound 
dressing  is  not  yet  fully  realized  by  the  public  in  general,  as  they 
have  become  imbued  with  the  necessity  of  frequent  change  of  dress- 
ing,   the  result   of  a   practice   that   dates  back   to  the  1:ime  when 
wounds  were  first  made  and  treated.      The  belief  in  healing  salves 
and  balsams  still   prevails.      Many  patients  whose  wounds^are  not 
dressed  every  day  feel  that  they  are  neglected,  and  regard  with  envy 
the  nearest  neighbor  whose  septic  wounds  receive  daily  attention. 
The  salve-box,  spatula,  baskets  of  lint  and  charpie,  pewter  syringes, 
and  slop-buckets  that  made  their  regular  daily  rounds  through'' all 
hospitals  less  than  a  quarter  of  a  century  ago  have  happily  disap- 
peared from  the  surgical  arena,  never  to  return.    The  ideal  dressino- 
material  is  hygroscopic  sterile  or  antiseptic  gauze.      For  years  sui^ 
geons  were  in  the  habit  of  impregnating  the  gauze  with  some  anti- 
septic.     The  antiseptics  that  have  been  emplo}'ed  most  extensively 
for  this  purpose  are  carbolic  acid,  bichlorid  of  mercury,  iodoform, 
salicylic  acid,  cyanid  of  mercur\',  and  boric  acid.      Lister's  original 
gauze  w^as  made  by  forcing  into  the  meshes  of  the  gauze  a  hot  mix- 
ture composed  of  crj'stallized  carbolic  acid  one  part,  resin  five  parts, 
and  paraffin  seven  parts.      The  resin  was  used  to  prevent  evapora- 
tion of  the  carbolic  acid,  and  the  parafifin  to  make  the  dressing  ad- 
hesive.     Later  the  bichlorid  of  mercury  and  iodoform  gauze,  pre- 
pared after  the  formula  proposed  by  Bruns,  had  a  very  extended 
trial.       Hygroscopic    antiseptic    cotton    came    into    use    later,  and 
remains   popular   with   the   profession  to  the  present  time.     Jute, 
oakum,   moss,   earth,   sand,   sawdust,   wood-wool,    and   filter-paper 
have  all   been  tried,  but  of  these  only  moss  and  wood-wool   have 
given  sufficient  satisfaction  for  the  continuation  of  their  employment, 
especially  in  the  hospitals  of  Germany. 

Romberg  has  made  some  very  interesting  experiments  to  deter- 
mine the  hygroscopic  capacity  of  the  following  dressing  materials. 
He  took  ten  grams  of  each,  weighed  them  again  after  complete 
saturation,  and  arrived  at  the  following  results. ' 

Ten  grams  of  dressing  material  weighed  when  full\-  saturated  : 

GRAMS.  GRAMS 

1.  Hygroscopic  cotton, 250  6.  Peat, 82  ' 

2.  Cell-fabric  cotton 230  7.  Popl'ar  sawdust^    '.'.'.'.'.'.'.  -77 

3.  \\  ofxl  fabric  cotton, 150  8.  Jute,  ....  -o 

4.  Wood-wool,      ,06  9.  Pine  sawdust,  .'    .'    .'    .'    .'    .'    .'    .'  53 

5-  <-'auze, ^5  jo.  Coal-ashes 21 

According  to  P'ehlei.scn,  cotton  absorbs  twice,  and  according  to 
Neuber  three  times,  as  much  as  gauze.  In  this  country,  with  few 
exceptions,  gauze  and  cotton  constitute  the  materials  which  are 
relied  upon  in  dre.s.sing  a  recent  wouiul  reciuiriiig  an  absorbent 
dressing.  Superficial  small  wounds  and  wounds  that  do  not 
secrete  do  not  require  an  absorbent  dressing.  Such  wounds  are 
sealed   hermetically  with  collodion,     'ihc  best  way  to  seal  such  a 


1 82  WOUNDS, 

wound  is  to  apply  a  strip  of  iodoform  gauze  that  slightly  overlaps 
the  margins  of  the  wound,  and  then  brush  collodion  over  it ;  the 
next  layer  is  a  little  larger,  and  is  again  sealed  in  place  with  col- 
lodion, and  over  this  a  third  strip  again  overlapping  the  second  is 
placed  and  saturated  with  collodion,  and  finally  a  thin  layer  of 
absorbent  cotton  is  fastened  in  a  similar  manner  over  the  last  piece 
of  gauze.  The  crust  that  forms  seals  the  wound  hermetically  and 
should  not  be  removed  until  the  wound  is  healed.  To  facilitate 
the  removal  of  the  crust  and  to  guard  against  stitch  abscesses  it  is 
advisable  to  bury  the  sutures  under  borosalicyhc  powder  before 
applying  the  collodion  crust.  Medicated  gauze  is  not  used  to  the 
same  extent  as  formerly.  In  the  dressing  of  wounds  that  have 
been  drained  and  that  are  expected  to  secrete  profusely,  borosali- 
cyhc acid  dusted  into  the  meshes  of  the  gauze  is  one  of  the  most 
efficient  antiseptics  in  preventing  putrefaction  of  the  wound  secre- 
tions in  the  dressings.  Gauze  and  cotton  used  as  dressing  mate- 
rials must  be  rendered  hygroscopic  and  sterile,  and  in  dressing 
aseptic  wounds  the  material  must  be  dry.  In  such  cases  the  dress- 
ing is  expected  to  absorb  the  wound  discharges  and  to  act  as  a 
filter  for  the  microbes  from  without.  The  dressing  must  be  absor- 
bent and  occlusive.  In  size  it  must  vary  with  the  dimensions  of 
the  wound  and  the  amount  of  wound  secretion  to  be  expected.  It 
is  a  very  common  mistake  to  make  the  dressing  too  small.  It 
should  be  made  to  extend  a  safe  distance  from  the  wound  and  to 
include  the  whole  disinfected  field.  The  gauze  must  be  applied 
loosely  and  not  in  layers,  as  loose  gauze  absorbs  more  freely  and 
can  be  made  to  fill  in  irregular  surfaces  much  more  readily  than  by 
using  gauze  in  the  form  of  compresses.  Around  and  over  the 
gauze  is  placed  a  thick  cushion  of  absorbent  cotton,  and  the  dress- 
ing is  confined  in  place  by  a  gauze  roller  instead  of  the  ordinary 
muslin  roller.  I  long  ago  abandoned  the  muslin  bandage  in  the 
dressing  of  all  wounds.  The  gauze  roller,  from  two  to  four  layers 
in  thickness,  is  more  elastic,  and  as  it  is  hygroscopic  and  sterile,  it 
constitutes  a  part  of  the  dressing.  The  best  iodoform  gauze  is 
sterile  gauze  into  the  meshes  of  which  iodoform  is  dusted.  To  fix 
the  iodoform  in  the  gauze  the  latter  should  be  moistened  with  sterile 
water  before  it  is  iodoformized. 

The  general  practitioner  should  obtain  his  dressing  material  from 
some  reliable  manufacturing  firm,  but  in  important  operations  it  is 
advisable  to  rested lize,  as  Schlange  and  others  found  bacteria  in 
antiseptic  gauze  that  was  obtained  from  different  sources  in  the 
open  market.  The  surest  way  to  sterilize  the  dressing  material  is 
by  steam  ;  steam  sterilization  can  be  relied  upon  in  rendering  the 
material  absolutely  sterile.  The  steam  to  be  effective  must  be 
saturated — that  is,  all  air  must  be  removed  and  replaced  by  steam  ; 
consequently  the  sterilization  must  be  done  in  a  closed  space.  The 
Boeckmann  sterilizer  is  the  one  which  the  general  practitioner  will 
find  most  economic,  convenient,  and  effective,  as  it  is  constructed 


ASEPTIC    AND    ANTISEPTIC    DRESSING    MATERIAL.  1 83 

upon  the  principle  that  oversteam  is  more  powerful  in  penetrating 
the  dressing  unitbrnih'  than  understeam.  Preliminary  heating  of 
the  material  is  important  in  rapid  sterilization.  Lister  aimed  to 
exclude  bacteria  from  the  dressing  by  applying  over  it  mackintosh 
cloth  ;  others  have  used  gutta-percha  tissue,  waxed  paper,  or  a  thin 
sheet  of  rubber  for  the  same  purpose.  This  part  of  the  dressing 
has  been  abandoned,  as  it  is  the  intention  now  to  keep  the  dressing 
dry,  thus  securing  one  of  the  conditions  retarding  germ  growth. 
Neuber  long  ago  emphasized  the  importance  of  dry  dressings  in 
the  treatment  of  recent  wounds.  The  most  recent  method  of  dress- 
ing is  no  longer  an  occlusive  dressing,  in  the  sense  in  Avhich  Lister 
and  Volkmann  used  this  term.  The  microbes  from  without  have 
free  access  to  the  dressing,  but  the  material  of  which  it  is  com- 
posed, especially  the  cotton  over  and  around  the  gauze,  constitutes 
an  efficient  filter. 

In  the  absence  of  proper  dressing  material  in  emergency  work 
the  surgeon  can  extemporize  a  dressing  that  will  answer  the  purpose 
from  an  aseptic  standpoint.  Linen  sheets,  towels,  napkins,  etc., 
can  be  made  hygroscopic  and  sterile  by  boiling  for  ten  minutes 
in  soda  solution,  after  which  the  soda  is  washed  out  in  sterile  cold 
water.  By  forcible  wringing  it  is  made  practically  dry,  and  of  the 
material  thus  prepared  wipers,  bandages,  and  gauze  can  be  made. 
Cheese-cloth  can  be  prepared  in  the  same  manner.  If  time  permits, 
the  dr}nng  of  the  material  can  be  completed  by  placing  it  on  sterile 
pans  for  a  few  minutes  in  the  oven  of  the  kitchen  stove.  If  the 
dressing  becomes  saturated  with  blood  or  serum  at  any  particular 
point,  it  is  not  necessary  to  remove  it,  as  was  formerly  done.  The 
saturated  area  should  be  dusted  freely  with  borosalicylic  powder,  and 
a  cushion  of  absorbent  cotton  applied  over  it  and  held  in  place  by  a 
gauze  bandage.  In  the  absence  of  more  urgent  indications  the  dress- 
ing should  remain  until  the  drainage-tube  has  been  removed — at 
the  end  of  the  second  to  the  fifth  day.  The  wounded  part,  if  it  is  one 
of  the  extremities,  should  be  placed  in  an  elevated  position,  at  an 
angle  of  45  degrees,  for  at  least  twelve  to  twenty-four  hours,  and 
properly  immobilized.  Splints  are  not  used  as  frequently  as  they 
should  be  in  the  treatment  of  wounds  of  the  soft  tissues.  Immobil- 
ization of  the  part  injured  or  operated  upon  constitutes  an  important 
part  of  the  wound  treatment,  as  it  aids  the  sutures  in  maintaining  the 
wound  surfaces  in  uninterrupted  contact,  and  secures  rest,  an  essen- 
tial condition  in  the  speedy  and  satisfactory  healing  of  the  wound. 
A  few  turns  of  the  plaster-of- Paris  bandage  over  the  dressing  will 
often  answer  the  purpo.sc,  and,  at  the  same  time,  will  also  prove  of 
great  service  in  keeping  the  dressing  in  close  contact  with  the  skin 
and  guarding  against  its  displacement.  In  large  wounds  of  the 
lower  extremities  a  splint  will  be  found  necessary  to  insure  rest  for 
the  wounded  part.  The  first  dressing  remains  as  long  as  it  answers 
the  indications  for  which  it  was  applied,  or  until  the  drain  must 
be  removed  or  indications  of  infection  present  themselves.       In  a 


1 84  WOUNDS. 

wound  that  has  not  been  drained  it  remains  until  the  sutures  must 
be  removed, — that  is,  a  week  or  two,  according  to  the  size  and 
nature  of  the  wound, — unless  signs  and  symptoms  of  infection 
necessitate  earlier  interference.  Frequent  unnecessary  changes  of 
the  dressing  interfere  with  the  conditions  necessary  for  an  ideal 
wound  healing,  and  always  expose  the  wound  more  or  less  to  post- 
operation  infection. 

In  wounds  that  have  been  drained  and  that  secrete  profusely, 
the  dressing  soon  becomes  saturated,  especially  in  places  to  which 
the  fluid  drains  most  frequently,  and  unless  the  surgeon  acts 
promptly,  the  dressing  may  become  a  source  of  infection  by  microbes 
from  without,  the  wound  secretion  answering  the  purpose  of  a  nutri- 
ent medium  for  their  reproduction  and  dissemination.  One  of  two 
things  becomes  necessary,  either  to  remove  the  dressing  and  replace 
it  by  another,  or  to  disinfect  the  surface  of  the  saturated  area 
and  apply  over  it  a  hygroscopic  aseptic  compress  of  cotton.  If 
the  saturation  appears  soon  after  the  dressing  is  applied  and  is 
extensive,  the  former  course  is  the  safer  one  to  pursue.  In  the  lat- 
ter case  the  moist  surface  is  freely  sprinkled  with  the  borosalicylic 
powder,  and  a  compress  of  absorbent  cotton  is  applied  and  held  in 
place  by  a  gauze  bandage.  For  the  purpose  of  minimizing  the 
quantity  of  wound  fluids  it  becomes  necessary  to  secure  complete 
hemostasis,  to  apply  a  large  absorbent  dressing,  and  to  keep  the 
wounded  part  in  an  elevated  position  for  at  least  from  twelve  to 
twenty-four  hours.  If  an  early  change  of  dressing  becomes  a 
necessity,  it  is  sometimes  advisable  not  to  expose  the  wound,  by 
leaving  a  limited  part  of  the  dressing  over  it  and  covering  it  well 
with  the  new  dressing.  Severe  pain  in  the  wound  and  indications 
of  the  existence  of  infection  always  demand  removal  of  the  entire 
dressing  to  enable  the  surgeon  to  inspect  the  wound  and  seek  for 
and  remove  the  cause  of  pain.  Should  the  wound  be  found  infected, 
the  necessary  changes  in  its  treatment  should  be  instituted  to  meet 
the  indications  presented  by  the  infection.  Renewal  of  the  bandage 
over  the  dressing  often  becomes  necessary  to  insure  accurate  con- 
tact between  it  and  the  surface  of  the  skin. 

ANTIPYOGENIC  AGENTS. 

After  Pasteur's  discovery  in  i860  of  the  causes  of  putrefaction, 
surgeons  rapidly  made  use  of  the  knowledge  thus  gained  in  their 
work  to  combat  wound  infection.  Lemaire  was  the  first  one  to 
practise  antiseptic  surgery  knowingly  and  intentionally,  but  his 
clinical  observations  were  insufficient,  and  the  principle  was  lost  in 
France.  Neudorfer  planted  the  new  idea  in  Germany  and  Gamgee 
in  England.  Lister  combined  the  ideas  of  others,  and,  after  reduc- 
ing them  to  a  scientific  whole  by  his  own  untiring  work,  laid  the 
foundation  of  a  new  era  in  surgery. 

The  first  efforts  directed  toward  the  prevention  of  wound  infec- 
tion consisted  exclusively  in  the   use   of  chemic  agents  that  were 


AXTIPVOGEXIC    AGENTS.  I  85 

known  to  be  destructive  to  animal  and  vegetable  life.  The  atmos- 
phere was  regarded  as  the  most  important  medium  lor  the  diffusion 
of  the  micro-organisms  that  were  supposed  to  be  suspended  in  the 
air,  and  were  regarded  as  the  cause  of  the  putrefactive  processes  in 
infected  wounds.  Lister's  spray  and  the  occlusive  dressings  were 
the  outcome  of  this  very  theor\^  regarding  the  cause  of  wound  in- 
fection. Bacteriologic  researches  since  that  time  have  demonstrated 
the  microbic  cause  of  nearl\-  all  of  the  infective  processes  that  the 
surgeon  is  called  upon  to  treat.  It  has  been  shown,  further,  that 
the  danger  of  wound  infection  arises  more  from  contact  than  from 
the  microbes  suspended  in  the  lower  strata  of  the  atmospheric  air. 
The  value  of  the  use  of  chemic  disinfectants  as  antipyogenic  agents 
has  been  greatly  overestimated,  and  their  place  has  been  largely 
taken  by  mechanical  cleansing  and  the  employment  of  heat  as  a 
germ  destroyer.  Many  surgeons  at  the  present  time  exclude  from 
their  practice  the  use  of  all  so-called  bactericidal  agents  and  achieve 
good  results.  Very  few  surgeons,  indeed,  continue  the  practice  of 
irrigating  fresh  wounds  with  antiseptic  solutions,  a  very  common 
procedure  during  the  early  history  of  antiseptic  surgery.  Experi- 
mental research  as  well  as  clinical  observations  have  demonstrated 
conclusively  that  irrigation  of  a  recent  wound  with  any  of  the 
stronger  antiseptic  solutions  is  not  only  superfluous,  but  harmful,  as 
it  increases  the  amount  of  wound  fluids  and  damages  the  tissues 
exposed  to  the  direct  action  of  the  antiseptic  used.  In  the  treat- 
ment of  recent  injuries  and  in  making  preparations  for  aseptic  oper- 
ations antipyogenic  measures  are  employed  at  the  present  time  more 
for  the  purpose  of  preventing  the  ingress  of  pathogenic  microbes 
into  the  wound  than  with  the  intention  of  destroying  them  after 
they  ha\'e  entered  the  wound.  With  such  an  object  in  view  the 
emj)loyment  of  antiseptics  has  a  wide  range  of  usefulness  that  will 
probably  never  be  entirely  abandoned.  Different  ways  and  means 
arc  now  resorted  to  in  the  struggle  against  microbes  that  threaten 
every  recent  wound.     Among  these  we  may  enumerate  : 

1.  Mechanical  measures  calculated  to  remove  bacteria  by  wash- 
ing, scrubbing,  scraping,  and  shaving. 

2.  Bactericidal  agents  which  destroy  the  microbes  by  heat  or 
chemic  action. 

3.  Inhibitory  remedies  which  do  not  kill  the  microbes,  but  which 
destroy  their  power  of  reproduction  in  the  tissues. 

4.  Antitoxic  agents  which  j^rove  useful  by  neutralizing  the 
toxins  without  exerting  any  particular  destructive  effect  on  the 
microbes  that  produced  them. 

5.  The  emplo)'ment  of  remetlics  not  directed  against  the  mi- 
crobes or  their  toxins,  but  which  are  intended  to  antagonize  their 
pathogenic  action  by  increasing  the  resistance  of  the  tissues  and 
the  body. 

The  mechanical  removal  of  microbes  from  the  hands,  the  surface 
of  the  body,  and  instruments  constitutes  the  most  important  anti- 


1 86  WOUNDS. 

pyogenic  measure  in  the  treatment  of  recent  wounds  and  in  making 
preparations  for  an  aseptic  operation.  Mechanical  cleansing  of 
everything  that  is  to  be  brought  in  contact  with  the  wound  prepares 
the  way  properly  for  subsequent  disinfection  and  sterilization.  The 
importance  of  this  part  of  the  technic  of  asepsis  can  be  readily  ap- 
preciated and  fully  understood  since  the  tangible  cause  of  infection 
is  known  to  consist  in  the  presence  in  the  wound  of  minute  living 
vegetable  organisms.  The  simple  cleansing  with  warm  water  and 
potash  soap  is  the  preparatory  act  of  each  disinfection,  and  the 
most  pedantic  cleanliness  on  the  part  of  the  surgeon  and  his  assis- 
tants constitutes  three-fourths  of  what  is  essential  to  the  prevention 
of  infection.  A  high  temperature  in  the  form  of  dry  heat,  steam,  or 
boiling  water  is  relied  upon  almost  exclusively  at  the  present  time 
in  effecting  sterilization,  and  alcohol,  carbolic  acid,  and  bichlorid  of 
mercury  are  the  antibactericidal  agents  most  frequently  resorted  to 
for  hand  and  surface  disinfection. 

Toussaint  and  Chauveau  have  demonstrated  by  their  experiments 
that  it  is  possible  to  render  anthrax  bacilli  harmless  by  exposing 
them  to  a  temperature  of  from  40°  to  55°  R.  Exposure  to  this 
temperature  does  not  destroy  the  bacilli,  but  deprives  them  of  their 
pathogenic  properties.  Since  that  time  mitigated  cultures  have 
been  employed  as  therapeutic  agents  in  the  treatment  of  divers  in- 
fective diseases.  The  researches  of  Behring  and  Kitasato  have 
shown  that  blood-serum  under  some  circumstances  possesses  the 
property  of  destroying  certain  bacterial  products  outside  and  inside 
of  the  animal  body.  It  has  been  ascertained  further  by  Charrin  that 
the  toxins  of  the  bacillus  pyocyaneus  are  capable  of  creating  an  im- 
munity in  rabbits  and  dogs  against  the  ordinary  pus-microbes. 
Among  the  infective  wound  diseases  in  man  there  is  only  one — 
hydrophobia — which  may  be  prevented  after  infection  has  occurred 
by  the  employment  of  an  antitoxic  remedy.  This  antitoxin  was 
obtained  by  Pasteur  from  the  spinal  cord  of  rabid  rabbits,  made  safe 
and  effective  as  a  prophylactic  therapeutic  agent  by  a  process  of 
mitigation  consisting  in  a  somewhat  complicated  process  of  desic- 
cation of  the  fresh  material.  Iodoform,  the  most  reliable  antibacil- 
lary  remedy  known  at  the  present  time  in  the  local  treatment  of 
tubercular  affections  uncomplicated  by  pyogenic  infection,  does  not 
destroy  the  bacillus  of  tuberculosis,  but  exerts  an  inhibitory  action 
and  neutralizes  its  toxins.  It  is  undoubtedly  to  the  latter  effect  that 
it  owes  its  decided  therapeutic  properties. 

ANTISEPTICS. 
Antiseptics  are  all  chemic  substances  that  have  been  used  to 
destroy  or  render  harmless  pathogenic  microbes  that  are  known  to 
be  causes  of  infection.  Asepsis  is  the  precious,  hard-earned  reward 
for  faithful  antiseptic  labor.  The  first  bactericidal  agent  employed 
in  surgery  for  the  purpose  of  destroying  the  cause  of  wound  infection 
was  carbolic  acid.      It  still  holds  an  enviable  place  among  the  anti- 


ANTISEPTICS.  187 

septics  in  use  at  the  present  time,  but  a  long  list  of  substitutes  has 
been  introduced  into  practice,  numbers  of  which  have  proved  them- 
seh'es  formidable  competitors.  The  virtues  of  the  different  anti- 
septics have  been  ascertained  experimentally  by  the  treatment  of 
pure  cultures.  Silk  threads  contaminated  with  pure  cultures  and 
exposed  to  the  action  of  the  different  antiseptics  have  formed  the 
basis  for  such  experiments.  It  was  soon  ascertained  that  the  spores 
are  much  more  resistant  to  the  action  of  antiseptics  than  the 
microbes  themselves.  The  surgeon  has  to  deal  with  these  spore- 
bearing  microbes, — the  bacillus  of  anthrax,  tuberculosis,  and  tetanus, 
— and  always  takes  the  spore-bearing  microbes  into  consideration 
in  selecting  the  antiseptic  and  in  grading  its  strength  in  the  treat- 
ment of  the  diseases  to  which  they  give  rise.  The  sporeless 
microbes  most  frequently  met  in  surgical  practice  are  the  ordinary 
pus-microbes,  the  staph}dococcus,  the  streptococcus  pyogenes,  the 
streptococcus  er\-sipelatis,  the  bacillus  mallei,  the  bacillus  of  diph- 
theria, and  the  colon  bacillus.  Of  all  known  microbes,  the  anthrax 
bacillus  and  its  spores  are  most  resistant  to  all  germ-destroying 
agents,  and  hence  this  microbe  is  usually  taken  as  a  standard  in 
estimating  the  bactericidal  properties  of  the  different  antiseptics 
employed  in  surgical  practice.  It  must  not  be  forgotten  that  the 
same  organism  under  different  circumstances  varies  considerably  in 
its  resisting  power. 

Difficulties  are  encountered  in  testing  the  antiseptic  prop- 
erties of  different  chemic  substances,  as  unless  great  care  is  ex- 
ercised, some  of  the  antiseptic  solution  used  for  disinfection  is 
conveyed  with  the  contaminated  thread  to  the  culture-medium. 
Geppert,  for  the  purpose  of  eliminating  this  source  of  fallacy, 
chemically  neutralized  the  antiseptic  employed  before  transferring 
the  thread  to  the  nutrient  medium. 

In  the  fifth  edition  of  his  classic  treatise,  "  A  Guide  to  the  An- 
tiseptic Treatment  of  Wounds,"  published  in  1887,  von  Nussbaum 
discussed  eighty  antiseptics  that  had  come  into  use  up  to  that  time. 
The  list  has  grown  materially  since  then,  but  a  visit  to  any  of  the 
large  hospitals  would  furnish  ample  proof  of  the  fact  that  but  few 
of  the  many  antiseptics  proposed  have  stood  the  test  of  experience. 
The  well-known  toxic  properties  of  the  two  most  reliable  antisep- 
tics— carbolic  acid  and  corrosive  sublimate — have  induced  surgeons 
to  seek  for  and  use  antiseptics  that  would  be  less  objectionable  and 
at  the  same  time  similarly  efficient  in  the  prevention  of  infection. 
The  anti.septics  entitled  to  confidence  are  the  following,  arranged  in 
alphabetic  order  : 

Acetate  of  aluminum  is  a  nontoxic  and  highly  valued  antisep- 
tic. It  can  he  used  in  large  quantities  without  fear  of  intoxication 
or  local  irritation.  Pinner  has  shown  that  a  2^  per  cent,  solution 
arrests  the  development  of  microbes  in  twenty-four  hours.  As  it 
injures  instruments  and  roughens  the  hands,  it  is  not  used  in 
operations.      Its  use  is  almost  entirely  limited  to  the  treatment  of 


1 88  WOUNDS. 

infected  wounds,  either  in  the  form  of  a  hot,  moist  compress  wrung 
out  of  a  saturated  solution,  or  for  continuous  irrigation.  For  the 
latter  purpose  it  has  no  equal.  A  i  per  cent,  solution  can  be 
made  by  mixing  twenty-four  grams  of  alum  and  thirty-eight  grams 
of  acetate  of  lead  with  one  quart  of  sterile  water.  In  the  treat- 
ment of  suppurativ^e  arthritis,  suppurating  compound  fractures,  and 
extensive  phlegmonous  inflammation  permanent  irrigation  with  a 
saturated  solution  is  absolutely  safe  and  most  effective. 

Alcohol. — x\lcohol  is  a  reliable  antiseptic,  and  as  such  is  used 
at  the  present  time  the  world  over.  Its  antiputrefactive  effect  has 
been  demonstrated  for  a  long  time  in  the  museums  in  the  preserva- 
tion of  organic  material  of  all  kinds.  The  antiseptic  properties  of 
wine  and  the  different  concentrated  alcoholic  liquors  of  all  kinds 
depend  on  the  amount  of  alcohol  they  contain.  Its  external  use 
is  not  attended  by  any  danger  from  absorption  in  toxic  quantities, 
through  the  skin  or  granulating  surfaces,  by  prolonged  or  extensive 
application,  and  it  is  therefore  applicable  for  hand  and  surface  dis- 
infection under  all  circumstances,  regardless  of  the  age  and  general 
condition  of  the  patient.  Additional  advantages  are  that  it  is  ob- 
tainable in  almost  all  localities,  and  does  not  lose  its  antiseptic 
properties  by  age,  as  is  the  case  with  many  of  the  more  potent 
antiseptics.  It  is  generally  used  in  full  strength.  Its  solvent 
action  on  fatty  substances  enhances  its  disinfecting  power. 

In  his  last  paper  on  hand  disinfection,  read  before  the  American 
Surgical  Association  in  1899,  Kocher  makes  the  statement  that 
alcohol  is  the  only  antiseptic  he  uses,  and  there  are  many  other 
surgeons  who  have  the  same  degree  of  confidence  in  its  disinfecting 
quality.  In  my  practice  also  the  local  use  of  alcohol  has  been 
found  very  effective  in  the  treatment  of  erysipelatous  inflammation 
and  other  forms  of  acute  superficial  lymphangitis. 

Boric  acid  is  a  mild,  nontoxic  antiseptic.  It  is  soluble  in 
water  in  the  proportion  of  3.5  :  100.  It  was  introduced  into  sur- 
gery as  an  antiseptic  by  Lister.  In  combination  with  salicylic  acid 
it  constitutes  one  of  the  antiseptics  in  Thiersch's  solution,  which  has 
a  most  extended  field  of  usefulness  in  surgery.  Thiersch's  solution 
is  composed  of  salicylic  acid  2  parts,  boric  acid  1 2  parts,  and  water 
1000  parts.  Boric  acid  in  powder  is  frequently  used  in  dr\'  dress- 
ings for  recent  wounds  ;  in  solution  it  serves  as  a  mild  disinfectant 
for  mucous  cavities,  as  a  local  application  by  moist,  hot  compress 
in  the  treatment  of  infected  wounds,  and  as  a  valuable,  clean  substi- 
tute for  poultices  in  the  treatment  of  dermatitis  and  phlegmonous 
inflammation. 

Bromin  is  a  powerful  antiseptic,  and  was  used  quite  extensively 
in  the  concentrated  form  during  the  Civil  War  in  the  treatment  of 
hospital  gangrene.  A  solution  of  i^  of  i  to  i  per  cent,  made  with 
potassic  bromid  is  a  valuable  deodorant  and  disinfectant  in  the 
treatment  of  moist  gangrene  and  profuse  suppuration  when  used  as 
an  antiseptic  in  moist  dressings  or  for  irrigation  or  injection. 


ANTISEPTICS.  189 

Camphor. — Camphor  preparations  have  been  used  for  a  long 
time  as  preservatives.  The  antiputrefactive  action  of  camphor  is 
generally  recognized.  Gangrenous  ulcers  improve  rapidly  under 
the  local  use  of  pulverized  camphor.  It  is  a  potent  cardiac  stimu- 
lant, and  one  of  the  most  reliable  of  the  long  list  of  antaphrodisiac 
remedies. 

Carbolic  acid  is  intimately  associated  with  the  origin  and  devel- 
opment of  antiseptic  surgery,  as  it  was  the  first  antiseptic  used  by 
Lister,  and  no  other  antiseptic  has  been  able  to  displace  it  entirely. 
In  the  concentrated  form  its  action  is  caustic.  The  strength  of  the 
solutions  emplo}-ed  has  varied  from  i  to  5  per  cent.  It  is  a  strong 
poison.  It  is  rapidly  absorbed  from  the  mucous  surfaces  and  more 
slowly  from  the  skin.  The  rapidity  with  which  it  is  absorbed  by 
mucous  membranes  and  serous  surfaces  contraindicates  its  use  in 
the  rectum,  peritoneal  and  pleural  cavities,  and  vagina.  During  the 
time  the  carbolized  spray  constituted  so  important  a  part  of  the 
antiseptic  technic  many  cases  of  severe  intoxication,  and  not  a  few 
deaths,  occurred  from  its  use  in  that  manner.  Copious  irrigation  of 
large  wounds  with  strong  carbolic  acid  solutions  and  the  prolonged 
use  of  moist  carbolized  compresses  have  not  infrequently  been  fol- 
lowed by  similar  results.  The  smoky  urine  so  frequently  seen  when 
carbolic  acid  was  in  daily  use  was  a  familiar  demonstration  to  every 
surgeon  of  the  rapid  absorption  of  this  antiseptic  through  mucous 
membranes,  skin,  wound,  and  ulcerated  surfaces.  Children,  the 
aged,  and  patients  suffering  from  renal  disease  are  particularly  sus- 
ceptible to  the  toxic  effect  of  carbolic  acid.  I  am  familiar  with  a 
case  in  which  death  resulted  in  a  few  hours  from  acute  intoxication 
from  the  application  of  pure  carbolic  acid  to  a  small  wound  inflicted 
by  a  dog,  the  patient  being  a  young  boy.  Dilatation  of  the  pupils, 
striking  pallor,  subnormal  temperature,  c3'anotic  lips,  an  extremely 
rapid  paralytic  respiration,  and  a  feeble  pulse  are  the  most  prominent 
symptoms  of  acute  carbolic  acid  intoxication.  Some  persons  are 
extremely  susceptible  to  the  toxic  action  of  carbolic  acid,  and  as 
the  existence  of  such  an  idiosyncrasy  can  not  be  predicted,  caution 
in  the  employment  of  this  antiseptic  is  always  necessary.  In  young 
children,  marasmic  subjects,  and  persons  the  subjects  of  renal 
disease  it  should  not  be  used  to  any  extent.  For  general  use 
the  strength  of  the  solution  should  not  exceed  2i/^  per  cent.  I 
have  seen  serious  results,  and  in  one  case  death,  follow  injection 
of  a  few  drops  of  pure  carbolic  acid  into  the  sac  after  tapping 
for  hydrocele.  Carbolic  acid  has  also,  under  certain  unknown 
conditions,  a  decided  local  toxic  effect.  Gangrene  of  a  finger  has 
been  repeatedly  seen  after  the  local  use  of  carbolic  acid  in  the  treat- 
ment of  ti'ivial  affections  or  insignificant  injuries.  Another  very 
distressing  result  of  tiic  local  use  of  carbolic  acid,  even  when  a 
weak  solution  is  used,  is  acute  dermatitis.  This  ill  effect  has  been 
attributed  by  Nussbaum  and  others,  so  long  as  the  original  Lister 
gauze  was  in  use,  to  the   action  of  resin   or  paraffin,  but  acute  in- 


190 


WOUNDS. 


flammation  of  the  skin  has  been  seen  following  the  application  of 
carbolized  solutions  since  the  adhesive  gauze  has  been  abandoned. 
If  the  surgeon  decides  to  use  carbolic  acid  as  an  antiseptic,  it  be- 
comes an  important  duty  on  his  part  to  be  on  guard  for  signs  or 
symptoms  that  announce  the  incipient  stage  of  general  or  local  in- 
toxication, and  in  such  an  event  at  once  to  remove  what  can  be 
secured  of  the  antiseptic  and  substitute  for  it  a  safer  one. 

Chloral  hydrate  is  an  antiseptic  of  some  value  in  the  treatment 
of  chronic  irritable  ulcers.  Concentrated  solutions  act  as  caustics. 
For  a  moist  antiseptic  dressing  a  i  per  cent,  solution  will  answer 
a  useful  purpose,  possessing  antiseptic  and  anodyne  properties. 

Chlorid  of  lime  was  used  by  Nussbaum  in  the  treatment  of 
wounds  as  early  as  1 860,  and  the  results  were  better  than  those 
from  any  other  remedy.  Chlorin  water  retains  its  reputation  in 
counteracting  putrefaction  in  the  treatment  of  foul  ulcers  and 
sloughing,  fetid,  open  carcinoma.  Chlorid  of  lime  is  still  preferred 
by  some  surgeons  to  any  other  antiseptic  for  hand  disinfection. 
After  washing  and  cleansing  the  hands  in  the  usual  way,  a  crystal 
of  sulphate  of  soda  is  placed  on  the  palm  of  one  hand,  and,  after 
rubbing  the  moistened  surfaces  for  some  time,  the  rubbing  is  con- 
tinued by  using  chlorid  of  lime,  after  which  the  hands  are  cleansed 
in  sterile  water.  R.  F.  Weir  is  a  strong  advocate  of  this  method 
of  hand  disinfection. 

Chlorid  of  sodium  in  the  strength  of  normal  blood-serum  is  a 
very  mild  antiseptic,  and  has  at  the  present  time  the  most  exten- 
sive use  in  the  treatment  of  recent  wounds.  The  normal  salt  solu- 
tion, Y^Q-  of  I  per  cent.,  is  now  in  constant  use  for  cleansing  recent 
wounds  and  the  field  of  operation,  and  has,  for  good  reasons, 
almost  entirely  taken  the  place  of  sterilized  water  in  the  operating 
room.  This  solution  does  not  damage  the  tissues  like  sterile  water, 
and  consequently  its  contact  Avith  recent  wound  surfaces  does  not 
interfere  with  an  ideal  process  of  repair. 

Chlorid  of  zinc  is  one  of  the  strongest  caustics,  and  as  such 
has  been  used  for  a  long  time  in  removing  malignant  and  other 
tumors.  Lister  recommended  an  8  per  cent,  solution  for  the  dis- 
infection of  infected  wounds,  and  for  such  an  indication  its  em- 
ployment has  proved  more  successful  than  that  of  any  other  anti- 
septic. I  have  always  used  a  10  per  cent,  solution,  and  have  found 
it  to  be  the  most  valuable  antiseptic  for  secondary  disinfection. 
The  solution  is  applied  to  the  surface  of  the  wound  after  thor- 
oughly cleansing  and  drying  it  with  a  cotton  swab,  with  which 
every  nook  and  corner  is  brushed  over  gently,  so  that  the  solution 
comes  in  contact  with  the  whole  infected  surface.  Enlargement  of 
the  wound  often  becomes  necessary  for  a  more  thorough  applica- 
tion of  the  antiseptic,  and  this  is  more  especially  important  in  the 
secondary  disinfection  of  an  infected  compound  fracture.  As  a 
solution  for  recent  wounds  it  has  been  used  in  the  strength  of -|-  of 
I  per  cent,  to  5  per  cent.,  but  since  antiseptic  irrigation  of  recent 


ANTISEPTICS.  191 

wounds  has  been  abandoned,  chlorid  of  zinc  is  seldom  used  in 
aseptic  operating  rooms. 

Chromic  acid  is  said  to  be  twenty  times  stronger  as  an  antiseptic 
than  subHmate,  and  ten  times  stronger  than  carboHc  acid,  and  yet 
it  has  not  found  its  way  to  any  extent  into  surgical  practice.  Its 
most  extensive  use  has  been  in  the  preparation  of  catgut,  which  by 
its  action  is  made  more  durable,  as  was  first  shown  by  Lister. 

Corrosive  sublimate  is  the  mercurial  preparation  that  has  had 
the  most  extended  use  and  that  has  given  the  best  satisfaction  as  an 
antiseptic  in  the  practice  of  surgery.  Koch  called  attention  to  the 
potent  antiseptic  properties  of  bichlorid  of  mercury  by  his  experi- 
ments, which  demonstrated  that  the  bacillus  of  anthrax  is  destroyed 
by  a  solution  of  i  :  20,000  of  water,  and  the  growth  of  the  same 
microbe  is  inhibited  by  a  solution  of  i  :  300,000  of  water.  Von 
Bergmann  introduced  it  first  as  a  surgical  antiseptic,  and  the  classic 
paper  of  Kiimmel  secured  for  it  a  speedy  and  extensive  trial  by  the 
profession  in  all  countries  where  antiseptic  surgery  is  practised. 

Corrosive  sublimate  is  incompatible  with  all  metallic  substances  ; 
it  has  therefore  never  been  used  for  the  sterilization  of  instruments, 
and  for  the  same  reason  the  solutions  must  be  kept  in  glass,  porce- 
lain, japanned,  or  wooden  vessels.  It  is  one  of  the  most  potent 
antiseptics  known,  but,  unfortunatel\-,  it  is  at  the  same  time  also  a 
very  dangerous  poison.  Like  carbolic  acid,  it  is  readily  absorbed 
through  mucous  membranes  and  even  through  the  intact  skin.  It 
is  never  used  in  disinfecting  mucous  passages,  and  care  is  necessary 
in  its  use  for  hand  and  surface  disinfection.  The  health  of  many 
surgeons  has  been  permanently  impaired  by  the  frequent  use  of 
strong  solutions  for  hand  disinfection,  and  man}'  severe  intoxica- 
tions have  resulted  from  its  local  use  in  the  treatment  of  wounds. 
Its  use  is  contraindicated  in  the  case  of  infants  and  young  children 
and  in  patients  the  subjects  of  advanced  renal  disease.  Its  local 
toxic  effects  are  manifested  by  itching,  burning  sensations,  and 
dermatitis,  which  often  extends  be}'ond  the  surface  to  which  the 
solution  was  applied,  and  frequently  terminates  in  the  formation 
of  blisters. 

The  symptoms  that  denote  general  intoxication  consist  in  dizzi- 
ness, restlessness,  prostration,  vomiting,  inflammation  of  the  mucous 
membrane  of  the  mouth,  bleeding  from  the  swollen  gums,  saliva- 
tion, bloody  diarrhea,  colitis,  proctitis,  tenesmus,  nephritis  with  fatty 
degeneration  and  calcification  of  the  tubuli  uriniferi,  which  in  many 
in.stances  have  resulted  in  death.  As  soon  as  the  first  symptoms 
of  local  or  general  intoxication  appear,  the  further  use  of  the  remedy 
must  be  promptly  suspended  and  as  much  of  the  antiseptic  as  can 
be  reached  must  be  removed,  and  in  its  place  a  milder  and  safer 
preparation  substituted.  The  gastro-intestinal  irritation  must  be 
alla\x-d  by  ap[)roi)riate  remedies  and  a  milk  diet  combined  with  egg- 
albumen. 

For  hand  and  surface  disinfection  a  solution  of  i  :  1000  of  water 


192 


WOUNDS. 


is  usually  used.  It  is  advisable  to  color  the  solution  with  anilin  blue, 
so  that  it  can  not  be  mistaken  for  water.  In  my  practice  the  carbolic 
acid  solution  is  colored  a  light  red  with  eosin,  and  the  normal  salt 
solution  yellow  by  adding  a  few  drops  of  the  tincture  of  curcuma. 

Corrosive  sublimate  has  been  used  very  extensively  in  catgut 
preparation  and  in  the  manufacture  of  antiseptic  gauze  and  cotton. 
When  brought  in  contact  with  the  alkaline  wound  secretions  it 
enters  into  a  chemic  combination  with  the  albumin,  forming  an  inert 
albuminate  of  mercury.  With  a  view  to  preventing  this  chemic 
change  Laplace  recommended  the  addition  to  the  bichlorid  solution 
of  tartaric  acid  in  the  following  proportions  :  Bichlorid  of  mercury 
I  part ;  tartaric  acid  5  parts  ;  water  looo  parts,  a  formula  that  has 
been  extensively  adopted  and  that  has  given  great  satisfaction.  The 
toxic  effect  of  the  bichlorid  is  diminished  by  adding  to  the  solution 
chlorid  of  sodium,  which  favors  the  formation  of  albuminate  of  mer- 
cury and  increases  the  hygroscopic  capacity  of  the  dressing  material. 
Distilled  or  at  least  soft  water  must  be  used  for  the  solution.  For 
the  more  ready  and  accurate  preparation  of  the  solution  Angerer 
devised  tablets  composed  of  fifteen  grains  each  of  bichlorid  of  mer- 
cury and  chlorid  of  sodium,  colored  with  eosin,  which  are  admirably 
adapted  for  military  and  emergency  practice.  For  ordinary  use 
in  aseptic  surgery  a  solution  of  i  :  lOOO  is  usually  employed, 
although  the  prolonged  use  of  a  much  weaker  solution,  i  :  5000, 
will  answer  the  bacteriologic  requirements. 

Creasote. — Creasote  had  been  used  to  a  considerable  extent  in 
the  treatment  of  wounds  before  carbolic  acid  was  known.  It  was 
used  with  signal  success  during  the  Civil  War  in  the  treatment  of 
hospital  gangrene.  It  is  a  very  potent  antiseptic,  but  has  been 
almost  entirely  displaced  by  carbolic  acid  in  surgical  practice. 

Creolin,  like  carbolic  acid,  is  a  product  of  coal-tar,  and  has  been 
used  as  a  substitute  for  the  latter.  It  was  claimed  that  it  possessed 
all  the  virtues  of  carbolic  acid  minus  its  toxic  effects.  These  asser- 
tions are  not  supported  by  experience,  and  it  is  seldom  used  in  sur- 
gery at  the  present  time.  Mixed  with  water  it  forms  a  milky  fluid. 
As  a  local  application  it  is  used  in  the  strength  of  i  or  2  per  cent. 

Formic  Aldehyd  (CUp  =  HCOH).— Formic  aldehyd  was 
first  obtained  by  Hoffmann  by  the  slow  combustion  of  methyl 
alcohol  (CH  3 .  OH),  brought  about  by  a  spiral  of  platinum  wire 
(CH3 .  OH  +  O  =  H^O  +  HCOH).  It  was  also  produced  by 
distillation  of  barium  or  calcium  formate, 

Ba  (COOH)a  =  BaCO.  +  HCOH. 

Formic  aldehyd  is  a  gas  at  ordinary  temperatures.  On  stand- 
ing it  gradually  polymerizes  into  paraformaldehyd,  a  crystalline 
sohd  consisting  of  three  molecules  of  the  aldehyd  condensed  into 
one  molecule, 

SCHp^QHgO,,. 

Formic  aldehyd  is  soluble  in  water  and  alcohol.      It  occurs  com- 


ANTISEPTICS.  193 

mercially  as  formalin,  representing  its  aqueous  solution,  containing 
40  per  cent,  of  the  aldehyd. 

Formalin  when  exposed,  even  at  ordinary  temperatures,  will 
give  off  formaldehyd  \-apors.  On  allowing  formalin  to  evaporate, 
either  with  the  aid  of  heat  or  without,  its  vapor  will  condense  and 
deposit  solid  paraformaldehyd  (polymerized  formaldehyd)  upon  sur- 
rounding objects,  such  as  cotton,  gauze,  bandages,  etc. 

By  the  spontaneous  evaporation  of  the  paraformaldehyd  it  is 
again  split  up  or  converted  into  the  gaseous  formaldehyd,  to  act 
antiseptically  upon  contiguous  objects.  Hence  formalin  has  been 
recommended  to  the  surgeon  for  cleansing,  disinfecting,  and  deodor- 
izing sponges  with  a  i  per  cent,  solution  of  formaldehyd  (10  parts 
of  the  40  per  cent,  of  formalin  to  390  parts  of  water).  For  cleans- 
ing the  hands,  mstruments,  etc.,  a  similar  solution  is  recommended. 
It  answers  admirably  for  the  preservation  of  anatomic  preparations, 
as  the  action  of  formalin,  whether  upon  living  or  dead  organism, 
produces  a  hard,  leathery  compound  with  all  albuminoid  substances. 
Liebreich  emphasizes  the  use  of  formalin  in  the  form  of  vapor  for 
the  disinfection  of  clothing  in  closed  receptacles. 

Formalin  is  regarded  as  a  nontoxic  mercuric  chlorid  (bichlorid 
of  mercury).  It  is  not  only  to  be  preferred  on  account  of  this  non- 
poisonous  property,  but  also,  by  its  great  penetrability  when  applied 
in  the  gaseous  state,  as  a  disinfectant,  the  vapor  having  nearly  the 
density  of  air. 

Formalin,  when  used  to  disinfect  rooms,  is  regarded  as  more 
efficient  than  carbolic  acid,  sulphurous  acid,  chlorin,  and  bromin. 
A  noticeable  fact  is  that  formalin  does  not  tarnish  or  act  on  metallic 
surfaces,  and  that  when  deposited  as  paraldehj^d,  it  will  evaporate 
gradually  and  thus  continue  disinfection  in  a  moderate  degree. 

Hans  Avonson  ("  Deutsch.  med.  Wochenschr.,"  1892)  speaks 
of  the  remarkable  power  of  formaldehyd  in  resisting  putrefaction, 
and  experiments  made  with  the  bacillus  of  t}'phus,  staphylococcus 
aureus,  anthrax  bacilli,  etc.,  demonstrated  that  a  i  :  20,000  solu- 
tion of  formaldelu'd  inhibited  their  development.  He  found  also 
that  one  drop  of  the  aldehyd  added  to  10  c.c.  of  nutrient  bouillon 
or  to  10  c.c.  of  urine  prevented  putrefaction. 

J.  Shahl  ("  Pharm.  Ztg.,"  1893),  speaking  of  his  results  regard- 
ing the  antibacterial  action  of  formalin  and  its  applicability  as  a 
disinfectant,  states  that  there  is  no  other  known  substance  so  suitable 
for  disinfection  ;  that  even  corrosive  sublimate  (bichlorid  of  mer- 
cury) failed  in  his  experiments  to  ecjual  the  extraordinary  destruc- 
tive pcnver  of  formalin. 

P'ormic  aldehyd  is  not  considered  poisonous  to  human  life  unless 
breathed  in  large  quantities  and  for  several  hours.  The  antidote  is 
found  in  the  inhalation  of  ammonia  vapor,  which  at  once  converts 
the  aldehyd  into  the  odorless  hexamethylenamin, 

6CH./)     -f-       4Nir3       =.      (CIIj)gN^       +      6II,,0. 
Formaldehyd.         Anitnonia.       Hexamethylenamin.  Water. 

^3 


194 


WOUNDS. 


As  a  deodorant,  according  to  Schmidt,  formalin  does  not  disguise 
the  odor,  but  unites  with  odorous  substances  chemically  generating 
inodorous  compounds.  Formaldehyd  is  relied  upon  very  exten- 
sively in  the  disinfection  of  operating  rooms  and  of  clothing  ;  and 
formalin  is  a  valuable  antiseptic  for  sponge  and  hand  disinfection. 

Hydrogen  peroxid  is  a  perfectly  safe  and  very  valuable  anti- 
septic. It  is  used  almost  exclusively  in  antiseptic  surgery  in  the 
treatment  of  suppurating  wounds  and  fistulous  tracts.  Applied  to 
recent  wounds  its  also  acts  as  a  hemostatic.  Nussbaum  attributes 
its  hemostatic  effect  to  the  oxygen  gas  that  is  liberated  so  freely 
when  the  peroxid  of  hydrogen  comes  in  contact  with  the  blood 
and  tissues,  and  which  irritates  the  vasomotor  nerves,  causing  a 
retraction  of  the  cut  ends  of  the  vessels.  It  is  the  rapid  genera- 
tion of  oxygen  when  the  peroxid  is  poured  into  a  suppurating 
cavity  that  effects  so  excellent  a  mechanical  cleansing  by  forcing 
the  pus  to  the  surface  from  the  most  remote  nooks  and  corners  of 
the  cavity.  Injections  of  peroxid  of  hydrogen  are  valuable  in 
locating  abscess  cavities  and  in  determining  their  size  after  they 
have  opened,  and  often  materially  aid  in  making  counteropenings 
in  localities  difficult  of  access  by  distending  the  cavity.  The  same 
procedure  can  be  relied  upon  in  making  a  differential  diagnosis 
between  a  complete  and  an  external  incomplete  rectal  fistula. 
Some  caution  is  necessary  in  its  use,  either  as  a  diagnostic  or  a 
therapeutic  resource,  and  that  is  not  to  expose  the  suppurating 
cavity  to  too  much  tension  by  the  accumulation  of  oxygen,  as  by 
so  doing  pus  and  pus-microbes  might  be  forced  into  the  surrounding 
healthy  tissues  and  perchance  even  into  the  general  circulation. 
Whenever  it  can  be  done,  it  is  better  to  pour  than  to  inject  the 
peroxid  into  the  suppurating  wound  or  abscess,  as  by  so  doing  the 
danger  from  harmful  overdistention  is  entirely  avoided. 

lodin  has  no  decided  antipyogenic  properties,  and  its  present 
use  in  surgery  is  limited  almost  entirely  to  operations  for  tubercular 
affections.  In  operations  for  tubercular  glands,  joints,  and  tendon 
sheaths  a  i  per  cent,  iodin  solution  is  the  one  preferred  for  irriga- 
tion, if  this  is  deemed  necessary,  as  is  the  case  when  the  tubercular 
process  for  which  the  operation  is  performed  has  terminated  in 
extensive  caseation  or  abscess  formation.  A  solution  of  this 
strength  has  the  color  of  sherry  wine,  and  when  brought  in  con- 
tact with  the  wound  acts  as  a  potent  tissue  stimulant,  exciting  an 
active  phagocytosis,  so  important  a  condition  in  the  prevention  of 
a  local  recurrence.  The  same  solution  can  also  be  used  advan- 
tageously, with .  sterile  gauze  as  a  moist  compress,  as  a  local 
application  in  the  treatment  of  flabby  tubercular  granulations. 
Trichlorid  of  iodin  in  a  ^  to  ^  of  i  per  cent,  solution  as  an  injec- 
tion has  been  used  with  some  success  in  the  treatment  of  tubercular 
cystitis. 

Iodoform. — The  antiputrefactive  action  of  iodoform  was  well 
known  before  this  remedy  was  introduced  into  general  practice  by 


ANTISEPTICS.  195 

Mosetig  von  Moorhof  in  1880.  As  a  deodorant,  Nussbaum  made 
use  of  the  following  formula  :  Iodoform  10  parts  ;  sulphuric  ether 
70  parts  ;  distilled  water  200  parts,  and  found  it  most  efficient  in 
correcting  the  odor  in  cases  of  putrefactive  infection  in  osteomye- 
litic  cavities,  sloughing  ulcers,  and  ulcerating  malignant  tumors. 
Von  Moorhof  emphasized  its  antiseptic  properties  in  the  treatment 
of  recent  wounds,  and  on  his  recommendations  it  soon  found  its 
way  into  the  practice  of  surgeons.  More  extensive  experience 
soon  demonstrated  that  its  antipyogenic  properties  are  quite 
limited.  Rovsing  showed  by  his  experiments  that  pus-microbes 
continued  to  grow  on  nutrient  media  in  the  presence  of  iodoform. 
All  surgeons,  however,  agree  that  iodoform  applied  to  a  recent 
wound  has  a  most  beneficial  effect  in  diminishing  the  piimary 
wound  secretion,  and  that  it  exercises  at  least  an  inhibitory  effect 
on  the  growth  of  pathogenic  bacteria.  Iodoform  gauze  has  been 
used  extensively,  but  at  present  it  is  seldom  employed  as  an  exclu- 
sive dressing  for  wounds  except  in  special  localities.  Its  use  is 
continued  in  dressing  wounds  of  the  mouth,  vagina,  rectum,  and 
it  is  the  most  desirable  material  for  the  antiseptic  tampon.  Iodo- 
form holds  the  highest  place  in  the  treatment  of  open  tubercular 
affections,  and  when  applied  directly  to  the  tubercular  lesions  by 
intra-articular  injection,  it  is  almost  a  specific  in  certain  forms  of 
joint  tuberculosis  not  complicated  by  pyogenic  infection.  It  is 
useless  in  cases  of  mixed  infection.  For  parenchymatous  and  intra- 
articular injections  a  10  per  cent,  glycerin  emulsion  yields  the  best 
results.  Iodoform  gauze  can  be  extemporized  by  sprinkling  finely 
triturated  iodoform  into  the  meshes  of  moist  sterile  gauze.  It  is 
also  an  excellent  preparation  for  rendering  catgut  antiseptic  after 
it  has  been  sterilized. 

The  decided  toxic  effect  of  iodoform  has  made  surgeons  cautious 
in  its  use.  When  Billroth  first  used  it,  he  often  poured  two  or 
three  drams  of  the  powder  into  the  wound  after  joint  resection  and 
operations  on  bones,  but  the  numerous  cases  of  serious  and  even 
fatal  intoxications  that  have  been  since  recorded  have  taught  us  an 
important  lesson.  It  must  always  be  used  sparingly  in  children  and 
in  patients  suffering  from  organic  disease  of  the  kidneys.  Some 
persons  are  also  exceedingly  susceptible  to  the  local  toxic  effect 
of  iodoform.  A  rapidly  spreading  violent  dermatitis  is  not  an 
exceptional  occurrence.  I  have  seen  the  inflammation  start  in 
a  small  accidental  ^\■ound  treated  by  iodoform,  and  in  the  course 
of  a  few  days  extend  over  the  entire  limb  and  a  considerable  portion 
of  the  body.  The  itching  and  burning  in  severe  cases  are  very  dis- 
tressing. In  the  treatment  of  this  complication  the  removal  of 
every  particle  of  iodoform  is  essential,  after  which  the  appropriate 
local  remedies  for  the  dermatitis  are  indicated.  As  the  individual 
predis[Kjsition  to  the  toxic  action  of  iodoform  can  not  l)e  predicted, 
the  amount  of  the  remedy  on  first  trial  should  be  sm;dl,  and  on  the 
manifestation  of  the  first  unpleasant  symptoms  its  further  use  must 


196  WOUNDS. 

be  suspended.  Three  degrees  of  general  intoxication  have  been 
noted.  The  mildest  form  is  characterized  by  loss  of  appetite, 
nervous  depression,  and  melancholia,  while  the  patients  thus  affected 
complain  that  everything  smells  of  iodoform.  The  symptoms 
subside  gradually,  but  the  patient  does  not  recover  fully  for 
several  weeks.  The  second  degree  of  iodoform  intoxication  is 
marked  by  more  alarming  symptoms.  The  patient  is  mentally 
depressed  for  several  hours  each  day  for  from  four  to  six  weeks, 
does  not  recognize  his  relatives,  and  at  times  is  violently  delirious. 
Even  at  the  end  of  six  weeks,  after  the  patient  has  apparently  re- 
covered, iodoform  can  be  detected  in  the  urine.  After  a  period 
of  quiescence  of  somewhat  indefinite  length  the  original  symptoms 
reappear  and  continue  for  another  period  of  from  four  to  six  weeks, 
after  which  the  patient  usually  recovers,  especially  if  he  is  treated  by 
stimulants. 

Terrible  are  the  symptoms  that  inaugurate  iodoform  intoxica- 
tion of  the  third  degree.  One  or  two  days  after  the  operation 
the  patient  loses  his  appetite  completely  and  becomes  delirious, 
the  movements  become  slower  and  slower,  and  the  speech  becomes 
indistinct ;  stupor  and  prostration  follow  and  terminate  in  death, 
usually  after  two  or  three  days.  Few,  if  any,  recover  from  this 
grave  form  of  iodoform  intoxication.  We  have  reason  to  suspect 
that  many  cases  of  so-called  postoperation  insanity  were  in  reality 
cases  of  iodoform  intoxication,  and  some  of  the  deaths  attributed 
to  prolonged  shock  or  sepsis  were  due  to  the  same  cause. 

The  many  substitutes  for  iodoform  that  have  come  into  the 
market  do  not  represent  the  full  antiseptic  power  and  antibacillary 
action  of  this  drug. 

Juniper. — The  berries  and  alcoholic  preparations  of  the  needles 
and  wood  of  t\i&  Jiiniperus  comiminis  have  for  a  long  time  been 
known  for  their  antiseptic  properties.  Juniper  oil  is  a  potent  anti- 
septic, and  Kocher  has  recommended  it  for  the  preparation  of  cat- 
gut. Immersion  of  the  raw  material  in  the  oil  for  twenty-four 
hours  was  relied  upon  in  effecting  its  sterilization.  Oil  of  juniper  has 
never  been  used  for  any  other  purpose  in  antiseptic  or  aseptic  sur- 
gery. 

Lysol  is  a  soapy  fluid  very  closely  resembling  creolin  chemic- 
ally. Its  antiseptic  properties  become  apparent  in  a  solution  of  i 
or  2  per  cent.  The  toxic  effects  are  much  milder  than  those  of 
carbolic  acid,  and  as  it  does  not  irritate  the  skin,  it  is  often  employed 
for  hand  disinfection  and  for  preparing  the  cutaneous  surface  for 
operation. 

Peruvian  balsam  is  one  of  the  most  valuable  of  the  resinous 
antiseptics.  It  was  used  as  an  antiseptic  in  the  treatment  of  wounds 
by  L.  A.  Sayre  and  others  long  before  the  microbic  origin  of  sup- 
puration was  discovered.  It  is  a  strong  tissue  stimulant,  and  will 
hasten  the  process  of  repair  when  applied  to  sluggish,  pale,  and 
edematous  granulations.      Its  most  beneficial  effects  are  to  be  seen 


ANTISEPTICS. 


197 


in  the  treatment  of  tubercular  fistulous  tracts.  Its  curative  action 
is  enhanced  b}-  a  preliminary  cleansing  with  peroxid  of  hydrogen. 

Potassium  permanganate  is  a  powerful  deodorant  and  anti- 
septic. It  has  been  used  for  a  long  time  in  solutions  of  varying 
strength  to  correct  the  odor  of  moist  gangrene,  foul  ulcers,  and 
ulcerating  and  sloughing  malignant  tumors.  It  has  had  an  ex- 
tensive trial  in  conjunction  with  oxalic  acid  in  hand  disinfection, 
a  method  which  originated  in  the  Johns  Hopkins  Hospital,  and 
which  is  still  in  use  in  that  institution,  but  is  seldom  practised  else- 
where. This  method  was  relied  upon  for  nearly  an  entire  term  in 
the  Rush  Medical  College  Clinic  in  preparing  the  hands,  but  did 
not  prove  so  satisfactory  as  alcohol,  turpentine,  and  bichlorid  of 
mercury. 

Resorcin  is  soluble  in  water,  alcohol,  and  glycerin.  It  is  a  safe 
and  an  effective  antiseptic  in  solutions  of  from  3  to  5  per  cent. 
Under  its  influence  suppuration  is  promptly  diminished.  The  best 
results  are  obtained  by  using  it  in  the  form  of  a  hot,  moist  compress 
wrung  out  of  a  3  per  cent,  solution.  It  has  done  excellent  service 
as  a  local  application  in  gonorrhea,  cystitis,  and  various  inflamma- 
tory affections  of  the  skin. 

Salicylic  acid  is  one  of  the  safest  and  most  valuable  of  all  anti- 
septics known.  Its  introduction  into  surgerj^  we  owe  to  Thiersch. 
It  is  a  w^hite,  nontoxic  powder  that  does  not  decompose  on  expo- 
sure to  atmospheric  air.  The  stability  of  the  preparation  adds  to 
its  practical  therapeutic  value.  It  has  been  used  very  extensively 
in  the  preparation  of  dressing  materials,  as  it  has  been  incorporated 
with  nearly  every  substance  employed  as  an  absorbent  covering  for 
wounds.  It  is  only  slightly  soluble  in  water  ;  hence  it  has  been 
used  in  the  form  of  an  emulsion  (1:5)  when  a  stronger  preparation 
than  a  saturated  solution  was  required.  A  10  per  cent,  ointment 
with  vaselin,  lanolin,  or  glycerin  is  one  of  the  best  applications  for 
the  toxic  dermatitis  caused  by  corrosive  sublimate  and  iodoform. 
Its  solubility  and  antiseptic  properties  are  increased  by  combining 
it  with  boric  acid  (Thiersch's  solution).  Salicylic  acid  is  the 
remedy  par  excellence  for  occlusive  dressings  for  stab,  punctured, 
and  gunshot  wounds. 

Salol  contains  38  per  cent,  of  phenol.  It  is  insoluble  in  water. 
A  few  drops  of  a  concentrated  alcoholic  solution  added  to  a  glass- 
ful of  water  make  a  beautiful  opalescent  fluid  which  is  admirably 
adapted  for  disinfection  of  the  teeth  and  mouth,  probably  the  best 
preparation  for  preparing  the  cavity  of  the  mouth  for  operation. 
Like  salicylic  acid,  it  is  a  desirable  antiseptic  for  the  occlusive 
dressing  in  sealing  small  recent  wounds. 

Sulphurous  acid  is  a  disinfectant  of  great  value.  Mixed  with 
equal  parts  of  water  or  glycerin  it  destroys  all  kinds  of  bacteria. 
A  10  per  cent,  solution  is  useful  for  hand  and  surface  disinfection 
and  as  a  derjdorant. 

Thymol  enjoyed  for  some  time  a  good  reputation  as  an  antisep- 


198  WOUNDS. 

tic  in  Volkmann's  clinic,  through  the  observations  and  writings  of 
Ranke.  It  was  claimed  that  a  solution  of  yL  of  i  per  cent,  was 
sufficient  to  protect  wounds  against  infection.  Experience,  how- 
ever, soon  demonstrated  that  its  antiseptic  properties  were  feeble, 
and  that  it  could  not  be  relied  upon  to  the  exclusion  of  more  potent 
antipyogenic  agents  in  the  prevention  of  wound  infection.  It  forms 
an  important  constituent  part  of  listerine,  a  preparation  that  is  used 
quite  extensively  in  this  country,  in  and  out  of  the  profession,  as  an 
antiseptic.  The  odor  of  thymol  is  pleasant,  and  yL  of  i  per  cent, 
is  an  agreeable  addition  to  boric  or  resorcin  solutions  as  a  cleans- 
ing solution  for  the  teeth  and  mouth. 

Tinctura  benzoini  composita  is  one  of  the  best  antiputrefactive 
preparations,  and  has  proved  most  efficient  in  the  treatment  of  oral 
wounds.  If  the  wound,  after  excision  of  the  upper  jaw  or  after 
any  other  large  intra-oral  operation,  is  tamponed  with  a  strip  of 
sterile  gauze  saturated  with  the  tincture,  the  packing  may  remain 
for  a  week  without  any  putrefactive  changes  taking  place,  which  is 
more  than  can  be  said  of  any  other  antiseptic  in  this  particular 
locality.  The  gauze  thus  treated  is  adhesive  and,  if  properly 
applied,  remains  in  place  for  any  desirable  length  of  time. 

Turpentine. — The  resin  incorporated  in  salves  and  plasters  is  a 
potent  tissue  stimulant,  and  is  useful  in  the  treatment  of  indolent 
ulcers  and  in  repressing  fungous,  massive  granulations.  The  oil 
of  turpentine  is  one  of  the  most  valuable  antiseptics  for  hand  disin- 
fection and  for  preparing  the  field  for  operation.  It  dissolves  fat, 
penetrates  the  skin  deeply,  reaching  its  appendages,  and  can  be  relied 
upon  in  destroying  the  microbes  with  which  it  comes  in  contact,  at 
the  same  time  not  irritating  the  skin  to  the  same  extent  as  alcohol, 
carbolic  acid,  or  corrosive  sublimate.  It  is  the  antiseptic  above  all 
others  that  should  follow  the  use  of  hot  water  and  potash  soap  to 
prepare  the  way  properly  for  further  chemic  disinfection.  It  is,  at 
the  same  time,  a  valuable  hemostatic.  In  infected  wounds  secreting 
an  abundance  of  thin  pus  mixed  with  blood  days  after  the  operation, 
nothing  will  be  found  more  prompt  in  its  action  than  the  local 
application  of  turpentine. 

ANTISEPTIC  SOLUTIONS. 
Heat  is  the  cheapest  and  most  reliable  sterilizer.  Dry  and  moist 
heat  are  employed  almost  exclusively  at  the  present  time  in  the  sterili- 
zation of  all  kinds  of  dressing  material  and  instruments.  Antiseptic 
solutions  must  be  relied  upon  for  rendering  the  hands  and  the  part 
injured  or  to  be  operated  upon  surgically  clean.  Our  present 
means  for  procuring  this  condition  are  not  sufficiently  perfect  to 
deserve  the  name  sterilization,  as  it  must  be  generally  conceded 
that  the  most  painstaking  processes  of  disinfection  do  not  succeed 
in  procuring  absolute  asepticity  of  the  skin  or  of  any  of  the  mucous 
surfaces  subjected  to  any  of  the  known  procedures.  This  confession 
of  weakness  on  the  part  of  our  aseptic  precautions  should  not  deter 


ANTISEPTIC    SOLUTIONS.  109 

US  from  making  conscientious  use  of  antiseptics  in  preparing  the  hands 
and  the  field  of  operation,  as  the  nearer  we  approach  perfection, 
the  better  will  be  the  results.  A  rigid  pedantic  disinfection  practi- 
cally results  in  asepticity  in  the  great  majority  of  cases.  Nearly  all 
the  antiseptics  used  in  the  operating  room  for  disinfection  are  em- 
ployed in  the  form  of  aqueous  solutions.  The  alcoholic  solutions 
are  made  use  of  for  the  preservation  of  sterilized  ligature  and  suture 
material.  What  is  required  of  an  antiseptic  solution  is  not  only  its 
known  power  to  destroy  or  inhibit  pathogenic  microbes,  but  it  must 
be  at  the  same  time  adapted  for  its  practical  employment.  The 
disinfection  of  a  wound  is  something  different  from  the  disinfection 
of  a  contaminated  silk  thread,  as  done  in  the  laboratory  to  test  the 
potency  and  applicability  of  the  different  antiseptic  solutions.  No 
such  direct  contact  of  the  antiseptic  with  the  microbes  can  take 
place  in  wounds  as  in  the  test-tube  or  on  the  culture-plate.  In 
the  preparation  of  antiseptic  solutions  it  is  important  to  remember 
that  the  menstruum  holding  the  antiseptic  in  solution,  to  be  effec- 
tive, should  penetrate  the  tissues  deeply.  Koch  made  the  state- 
ment long  ago  that  solutions  in  oil  are  comparatively  inert,  as  they 
lack  the  power  of  penetration.  The  same  objection  can  be  made 
to  aqueous  solutions  if  they  are  used  with  the  object  of  destroying 
microbes  enveloped  in  fat.  Experiments  have  shown  that  the 
strongest  solutions  of  carbolic  acid  and  bichlorid  of  mercury  are 
almost  useless  if  the  microbes  are  protected  by  the  thinnest  film 
of  fat.  If  the  contaminated  threads  are  soaked  in  oil  before  expo- 
sure to  the  chemic  disinfectants,  some  of  the  bacteria  are  found 
active  after  days  of  exposure.  These  experiments  remind  us  for- 
cibly of  the  necessity  of  a  careful  removal  of  fat  by  washing  the 
part  injured  or  to  be  operated  upon,  as  well  as  the  hands  of  the 
operator  and  assistants,  in  hot  water  and  potash  soap,  and  of  re- 
moval of  all  fatty  material  that  may  have  escaped  the  mechanical 
cleansing,  by  scrubbing  with  solvents  of  fat,  such  as  alcohol,  sul- 
phuric ether,  or  turpentine  before  making  use  of  the  antiseptic 
solution.  In  general  practice  too  viucJi  importance  is  placed  upon  the 
germicidal  action  of  the  antiseptic  solutions,  and  not  enough  attention 
is  given  to  the  proper  preparation  of  the  parts  for  the  restricted  and 
legitimate  action  of  these  solutions. 

Glycerin  penetrates  the  tissues  very  readily,  and  should  on  this 
account  always  take  the  place  of  oil  as  a  vehicle  for  iodoform  and 
other  substances  used  for  intra-articular  and  parenchymatous  injec- 
tions. The  chemic  composition  of  the  substance  or  material  to  be 
disinfected  also  plays  an  important  role  in  the  disinfection  by  chemic 
agents.  It  is  not  immaterial  whether  the  bacteria  are  in  a  dry  state 
or  suspended  in  water,  urine,  blood,  s})utum,  or  feces,  as  the  chemical 
employed  as  an  antiseptic  may  form  compounds  that  detract  from 
its  disinfecting  power.  Fat,  albumin,  blood,  and  pus  constitute 
.serious  barriers  to  efficient  disinfection  by  forming  chemic  com- 
pounds with  the  disinfectant.      These  substances  offer  resistance  to 


200  WOUNDS. 

the  full  antiseptic  effect  of  the  most  powerful  of  all  antiseptics,  car- 
bolic acid  and  bichlorid  of  mercury.  The  antiseptic  solutions  that 
will  be  mentioned  further  on  are  intended,  in  the  first  place,  to  aid 
other  measures  in  procuring  for  everything  that  is  to  be  brought  in 
contact  with  the  wound  and  that  can  not  be  sterilized  by  heat,  prac- 
tically an  aseptic  condition, — that  is,  they  are  used  as  disinfectants, 
with  the  special  object  in  view  of  preventing  wound  infection, — and, 
in  the  second  place,  they  have  a  wide  range  of  application  in  the 
treatment  of  infected  wounds.  As  water  is  the  vehicle  usually 
employed  in  the  preparation  of  antiseptic  solutions,  it  is  well  to 
remember  that  according  to  Carl  Frankel  the  only  water  that  is 
absolutely  free  from  bacteria  is  that  which  issues  from  the  interior 
of  the  earth  ;  the  water  that  evaporates  from  the  surface  of  the  earth 
and  condenses  in  the  higher  cold  regions  of  the  atmosphere  is  also 
sterile,  but  when  it  descends  in  the  form  of  rain  or  snow,  it  becomes 
contaminated  by  the  microbes  floating  in  the  lower  strata  of  the 
air.  Contrary  to  the  opinion  usually  held,  rain-water  and  water 
from  melting  snow  are  bacteriologically  not  pure,  and  are  unfit  for 
antiseptic  solutions  without  boiling.  Well-  and  river-water  always 
contains  bacteria  and  requires  boiling  before  it  can  be  safely  used 
as  a  menstruum  for  the  antiseptic  solutions.  The  degree  of  con- 
tamination depends  on  the  nature  of  the  soil  and  the  number  of 
people  and  animals  inhabiting  certain  districts.  Fortunately,  most 
of  the  microbes  found  in  water  do  not  infect  wounds.  Pus-microbes, 
however,  have  been  found  repeatedly  in  spring-  and  river-water. 
Most  of  the  pathogenic  microbes  not  only  retain  their  vitality  in 
water,  but  they  often  multiply  in  it  with  surprising  rapidity.  Cramer 
ascertained  that  the  water  from  the  water-works  of  Ziirich  multiplied 
2700  times  in  a  (ew  days,  and  Leone  showed  that  the  water  from 
the  city  supply  of  Munich  contained  five  microbes  in  each  cubic 
centimeter ;  if  the  same  water  was  allowed  to  stand  for  five  days, 
they  increased  100,000  times.  Even  distilled  water  is  an  excellent 
culture-medium  for  some  kinds  of  saprophytes.  From  a  practical 
standpoint  it  must  be  taken  for  granted  that  septic  organisms  can 
live  for  a  long  time  in  water,  retaining  their  virulence  and  power  of 
reproduction.  It  is  fortunate  that  the  same  warfare  is  carried  on  be- 
tween different  kinds  of  micro-organisms  in  water  as  elsewhere,  so 
that  some  of  the  more  dangerous  microbes  are  destroyed  by  sapro- 
phytic and  other  comparatively  harmless  bacteria. 

From  the  foregoing  it  appears  plain  that  well-,  river-,  spring-, 
and  rain-water  should  not  be  brought  in  contact  with  fresh  wounds 
without  being  sterilized.  The  common  practice  among  laymen  of 
washing  wounds  with  water,  regardless  of  its  source,  must  be  con- 
sidered as  dangerous.  The  only  surgical  use  of  plain  water  is 
limited  to  scrubbing  of  floors,  ceiling,  walls,  and  furniture  of  the 
operating  room.  The  methods  of  filtration  so  far  devised  have  not 
succeeded  in  eliminating  from  water  all  sources  of  infection.  Fil- 
tration  on   a  small   scale  through  the   Chamberlain-Pasteur  filter 


ANTISEPTIC    SOLUTIONS.  20I 

yields  comparatively  pure  water,  but  in  the  course  of  time  the 
efficacy  of  the  filter  is  impaired,  as  at  the  end  of  four  days  bacteria 
make  their  appearance  in  the  water.  For  surgical  use  water  must 
be  sterilized  by  heat  or  chemic  agents.  Boiling  is  the  simplest  and 
most  reliable  method  of  sterilization.  Boiling  for  two  minutes 
destroys  the  most  resistant  organisms — the  spores  of  the  anthrax 
bacillus.  Boiling  for  five  minutes  suffices  under  all  circumstances 
to  render  the  water  absolutely  sterile.  It  should  not  be  forgotten 
that  boiling  has  no  influence  on  the  ptomains,  consequently  the 
clearest,  purest  water  should  be  used  and  sterilized.  Sterilization 
of  water  by  chemicals  is  a  slower  and  less  reliable  process.  Gep- 
pert  found  the  spores  of  the  anthrax  bacillus  alive  after  twenty -four 
hours  in  a  I  or  2  :  lOOO  solution  of  bichlorid  of  mercury,  which 
would  suggest  that  in  case  chemic  sterilization  is  relied  upon,  the 
antiseptic  solution  should  be  prepared  two  or  three  days  ahead  of 
its  expected  use,  which  is  certainly  out  of  question  in  emergency 
surgery.  Water  containing  carbonate  of  lime  can  not  be  used 
with  bichlorid  of  mercury,  as  much  of  the  antiseptic  would  be  lost 
by  combination  with  the  lime  salts.  If  no  water  free  from  lime  salts 
can  be  obtained,  such  a  chemic  change  can  be  prevented  by  adding 
acetic  or  tartaric  acid,  or,  still  better,  common  salt,  to  the  solution. 
Equal  parts  of  the  bichlorid  of  mercury  and  common  salt  are  the 
proper  proportion,  and  this  is  represented  by  Angerer's  tablets. 
Sterilization  of  water  b}'  boiling  can  be  done  either  before  or  after 
the  addition  of  the  antiseptic — preferably  before,  as  some  of  the 
antiseptics,  especially  the  bichlorid  of  mercury,  are  incompatible  with 
metal.  In  hospitals  and  private  offices  sterilized  water  can  be  kept 
on  hand  in  large  bottles  or  jugs,  well  corked. 

Carbolic  Acid  Solution. — Five  per  cent,  is  the  standard  solu- 
tion. It  should  be  colored  with  eosin  to  prevent  mistakes.  For 
hand  disinfection  the  strong  solution  (5  per  cent.)  is  used.  For 
the  disinfection  of  large  accidental  wounds  and  in  preparing  an 
extensive  field  of  operation,  a  2^  per  cent,  solution  will  suffice. 
The  214  per  cent,  solution,  made  by  mixing  equal  parts  of  the  5 
per  cent,  solution  and  sterile  water,  is  the  one  usually  employed  for 
washing  out  suppurating  joints  after  tapping,  parenchymatous 
injections,  hot,  moist  antiseptic  dressings,  and  irrigation  of  suppur- 
ating wounds.  Carbolic  acid  in  any  form  should  not  be  used  in 
infants  and  young  children,  and  must  be  used  with  great  caution 
in  anemic  marasmic  subjects  and  patients  suffering  from  organic 
di.seasc  of  the  kidneys. 

Bichlorid  of  Mercury  Solution. — The  standard  solution  is 
I  :  1000,  which  shcnild  be  colored  with  anilin  blue  and  properly 
labeled.  This  is  the  solution  most  generally  used  at  the  present 
time  for  hand  and  surface  disinfection.  Like  carbolic  acid,  it  is 
never  u.scd  in  the  disinfection  of  mucous  cavities  or  pas-sages.  For 
irrigation  of  suppurating  wounds  and  local  application  by  hot, 
moist  compress  the  strong  solution  is  diluted  from  two  to  five  times 


202  WOUNDS. 

for  the  purpose  of  diminishing  the  risk  of  intoxication,  and  it  is 
well  known  that  a  solution  of  i  :  100,000  exerts  an  inhibitoiy  action 
on  pathogenic  microbes.  Age,  complicating  diseases,  and  the 
general  condition  of  the  patient  must  be  carefully  considered  in 
searching  for  contraindications  to  the  use  of  this  potent  and  poison- 
ous antiseptic.  For  emergency  work  Angerer's  tablets,  composed 
of  fifteen  grains  each  of  bichlorid  of  mercury  and  common  salt, 
with  the  addition  of  eosin  as  a  staining  material,  recommend  them- 
selves for  accuracy  and  convenience.  By  dissolving  one  tablet  in  a 
quart  of  boiled  water  a  i  :  1000  solution  is  extemporized,  which 
can  then  be  diluted  to  the  desired  strength  by  the  addition  of  the 
requisite  amount  of  sterile  water. 

Acetate  of  Aluminum  Solution. — As  has  been  stated  be- 
fore, acetate  of  aluminum  is  a  nontoxic,  nonirritating,  mild  anti- 
septic. Its  use  is  limited  almost  entirely  to  the  treatment  of  in- 
fected wounds,  phlegmonous  inflammation,  and  permanent  irrigation 
of  suppurating  joints  and  large  abscess  cavities.  A  saturated  solu- 
tion can  be  used  freely  for  weeks  or  months  without  any  risk  of 
intoxication  whatever.  Acetate  of  aluminum  is  a  remedy  of  the 
utmost  value  in  antiseptic  surgery.  A  i  per  cent,  solution  can  be 
extemporized  by  dissolving  twenty-four  grams  of  alum  and  thirty- 
eight  grams  of  acetate  of  lead  in  one  quart  of  water.  A  compress 
saturated  with  this  solution  and  applied  directly  to  the  skin  in 
dermatitis  of  all  kinds  promptly  relieves  the  itching  and  burning, 
prevents  the  spread  of  the  disease,  and  promotes  the  process  of 
resolution.  I  always  substitute  for  the  dry  dressing  the  moist 
aluminum  compress  in  all  wounds  that  are  or  may  become  infected. 

Thiersch's  Solution. — A  combination  of  salicylic  and  boric 
acid  makes  a  very  efficient  and  safe  antiseptic  either  in  the 
form  of  powder  or  solution.  Boric  acid  increases  the  antiseptic 
properties  of  salicylic  acid.  Thiersch's  solution  is  made  by 
dissolving  half  a  dram  of  salicylic  acid  and  three  drams  of  boric 
acid  in  one  quart  of  sterile  water.  This  solution,  like  acetate  of 
aluminum  solution,  is  nontoxic  and  nonirritant,  and  is  used  to  meet 
the  same  indications.  It  is  safe  and  useful  in  disinfecting  the 
mouth,  rectum,  and  vagina  preliminary  to  an  operation.  It  is  the 
solution  of  choice  in  irrigating  large  suppurating  cavities,  as  is  the 
case  in  empyema,  suppurative  peritonitis,  and  synovitis,  and  in  wash- 
ing out  large  phlegmonous  abscesses.  It  comes  next  in  utility  to 
the  acetate  of  aluminum  solution  for  permanent  irrigation.  It  is 
the  antiseptic  solution  of  choice  in  the  surgery  of  infants  and 
young  children. 

Boric  Acid  Solution. — Boric  acid  is  a  mild  antiseptic,  and  in 
solution  is  used  for  indications  similar  to  those  in  which  Thiersch's 
solution  is  employed.  Three  and  a  half  per  cent,  constitutes  a 
saturated  solution.  Very  few  cases  of  intoxication  have  been  re- 
ported from  its  use.  The  moist  boric  acid  compress  is  an  admir- 
able substitute  for  the  old-fashioned,  filthy,  germ-breeding  poultice. 


ANTISEPTIC    POWDERS.  203 

Chlorid  of  Zinc  Solution. — A  lo  per  cent,  solution  of  chlorid 
of  zinc  is  the  strongest  weapon  in  the  attempt  to  transform  a  septic 
into  an  aseptic  wound.  The  wound  must  first  be  thoroughly- 
cleansed  and  dried  and  the  suppurating  surface  freely  exposed, 
when  the  solution  is  applied  with  a  cotton  swab  ;  after  a  few  min- 
utes the  excess  of  the  solution  is  washed  away  with  a  normal  salt 
solution,  and  the  wound  covered  with  a  hot,  moist,  antiseptic  com- 
press. The  chlorid  of  zinc  solution  penetrates  the  tissues  deeper 
than  any  of  the  other  antiseptic  solutions,  and  reaches  the  microbes 
some  distance  from  the  surface  of  the  wound.  Injected  into  the 
normal  tissues,  the  same  solution  acts  as  a  powerful  tissue  stimu- 
lant, and  has  been  recommended  by  Lannelongue  in  the  treatment  of 
peripheral  tubercular  affections  and  for.  the  radical  cure  of  hernia. 

Normal  Salt  Solution. — The  normal  salt  solution  is  prepared 
by  dissolving  y^^j-  of  I  per  cent,  of  chlorid  of  sodium  in  sterile 
water.  A  teaspoonful  of  salt  to  a  quart  of  water  represents 
approximately  the  strength  of  this  solution.  The  solution  corre- 
sponds in  its  degree  of  alkalinity  to  the  serum  of  blood,  and  it 
has  come  into  the  most  extensive  use  in  aseptic  surgery.  In  clean- 
ing recent  wounds  it  should  always  take  the  place  of  sterile  water, 
as  it  does  not  damage  the  tissues  like  the  latter.  The  same  solu- 
tion is  used  in  the  treatment  of  grave  hemorrhage  by  intravenous, 
subcutaneous,  and  rectal  infusion. 

Aqua  Binelli. — This  is  a  i  per  cent,  solution  of  creasote,  and 
has  proved  useful  in  the  treatment  of  fetid  suppuration  as  an  injec- 
tion and  a  local  application. 

Permanganate  of  Potash  Solution. — A  5  per  cent,  solu- 
tion of  permanganate  of  potash  is  a  reliable  germicide,  and  as 
such  can  be  used  for  hand  disinfection  and  for  the  disinfection  of 
suppurating  wounds.  In  the  strength  of  1,1^5-  of  I  to  I  per  cent,  it 
is  a  deodorant  that  can  be  employed  for  the  disinfection  of  the 
mouth  and  the  interior  of  fetid  abscesses. 

ANTISEPTIC  POWDERS. 
For  dry  dressings  in  the  treatment  of  small  recent  wounds 
some  kind  of  antiseptic  powder  is  of  great  value  in  preventing 
infection.  This  is  more  especially  true  in  penetrating  gunshot  and 
stab  wounds.  Suturing  in  such  cases  is  seldom  done,  and  primary 
disinfection  is  often  out  of  question  under  the  circumstances  under 
which  the  injury  is  inflicted.  The  antiseptics  in  powder  form 
may  not  destroy  the  microbes  on  the  surface  of  the  wound  and  the 
adjacent  skin,  but  they  will  prove  efficient  in  inliibiting  their 
growth.  Such  wounds  arc  treated  most  successfully  by  dusting 
them  with  a  potent  antiseptic  powder  before  the  dressing  is  applied. 
Antiseptic  powders  arc  also  in  extensive  use  in  dusting  the  line  of 
suturing,  and  unquestionably  contribute  much  toward  the 'preven- 
tion of  stitch  abscesses.  For  many  years  iodoform  has  been  used 
almost  exclu.sively  to  meet  both  of  these  indications.     The  odor, 


204  WOUNDS. 

expense,  and  comparatively  feeble  antiseptic  properties  of  this  drug 
are  valid  objections  to  its  general  use.      It  has  been  used  in  com- 
bination with  boric  acid,  and  the  results  have  been  equally  as  satis- 
factory as  when  the  pure  iodoform  was  used. 
lodoform-boric  Powder. — 

Iodoform, lOO  parts. 

Boric  acid, 5°°     " 

To  be  effective  the  antiseptic  powder  for  permanent  dressings 
should  resist  chemic  changes  to  a  maximum  degree  on  exposure  to 
atmospheric  air  or  when  brought  in  contact  with  the  primary 
wound  secretions.  For  several  years  I  have  made  use  of  a  com- 
bination of  salicyHc  and  boric  acids,  with  the  most  satisfactory 
results.     The  following  is  the  formula  for  the — 

Borosalicylic  Powder. — 

Boric  acid,      4  drams 

Salicylic  acid, i  dram. 

This  powder  is  particularly  well  adapted  for  the  treatment  of 
recent  gunshot  wounds. 

ANTISEPTIC  SALVES. 

The  typical  antiseptic  dressing  has  reduced  the  use  of  salves  in 
surgery  to  within  very  narrow  limits.  All  the  salves  in  use  at  the 
present  time  contain  one  or  more  antiseptics,  and  are  employed  as 
a  primary  wound  dressing  in  the  treatment  of  small  wounds,  espe- 
cially of  the  lips  and  face,  to  protect  granulating  surfaces,  and 
occasionally  as  a  protection  for  skin-grafts.  The  French  surgeons 
are  very  partial  to  what  they  call  the — 

Antiseptic  Pomade. — 

Antipyrin, 5  parts 

Boric  acid,      5      '< 

Iodoform, I  part 

Vaselin, 50  parts. 

As  a  protection  for  granulating  surfaces  and  as  a  dressing  after 
harelip  operations  and  small  wounds  of  the  face  I  have  found  the 
following  to  be  very  efficacious  : 

Borosalicylic  Ointment. — 

Boric  acid, ^  dram 

Salicylic  acid, lo  grains 

Glycerin  ointment, I  ounce. 

Lister's  Boric  Acid  Ointment. — 

Boric  acid, 3  parts 

Vaselin, 5     " 

Paraffin, ,    .     10    " 

Chloral  Hydrate  Ointment. — 

Chloral  hydrate, 
Gum  acacia, 

Powdered  camphor, of  each,       5  parts 

Vaselin, , 50     " 

The  last-named  ointment  is  a  soothing  application  in  all  forms 
of  dermatitis. 


THE    MECHANICAL    TREATMENT    OF    WOUNDS.  205 

Unguentum  Crede. — The  silver  ointment  of  Crede  is  said  to 
penetrate  the  intact  skin  and  exert  its  antipyogenic  effect  on  the 
bacteria  in  the  tissues.  It  has  been  used  with  success  not  only  in 
lymphangitis  of  the  skin,  but  also  in  deep-seated  phlegmonous  in- 
flammation. It  is  not  essential,  according  to  Crede,  that  the  inunc- 
tion should  be  made  directly  over  the  affected  part  in  order  to  secure 
its  antipyogenic  effect  on  infected  processes  distant  from  the  surface 
of  the  body. 

THE  MECHANICAL  TREATMENT  OF  WOUNDS. 

The  dangers  from  infection  incident  to  any  open  wound  have 
been  described  in  detail,  as  well  as  the  methods  best  calculated  to 
arrest  or  minimize  them.  The  mechanical  treatment  comes  next 
in  importance  to  aseptic  and  antiseptic  precautions  in  the  modern 
treatment  of  wounds.  Without  the  observance  of  the  latter, 
mechanical  measures  are  of  but  little  value  in  aiding  nature's 
resources  in  wound  healing,  and  have  often  become  a  source  of 
danger,  as  has  been  abundantly  shown  by  the  experience  of  the 
past.  The  mechanical  aids  in  the  treatment  of  a  wound  are  of  the 
greatest  importance  and  of  signal  service  in  cases  of  incised  aseptic 
wounds,  such  as  are  made  by  the  surgeon's  knife,  under  strict 
aseptic  precautions. 

The  mechanical  treatment  of  a  wound  consists  in  a  recourse  to 
such  measures  as  will  bring  and  hold  in  accurate,  uninterrupted 
contact  the  wound  surfaces,  and,  at  the  same  time,  procure  for  the 
part  injured  a  condition  approaching  physiologic  rest,  in  a  position 
best  calculated  to  favor  restitution  of  the  continuity  of  the  severed 
tissues  and  the  reestablishment  of  the  interrupted  circulation. 
The  first  indication  in  securing  an  ideal  mechanical  coa])tation 
of  the  surfaces  that  it  is  intended  to  unite  is  to  remove  all  sub- 
stances that  would  interfere  with  such  approximation  and  that 
would  otherwise  be  detrimental  to  the  process  of  healing.  Before 
any  attempts  are  made  to  unite  a  wound,  it  must  be  made  clean, 
and  this  includes  careful  hemostasis  and  the  removal  of  foreign  sub- 
stances and  tissues  not  adapted  to  the  process  of  repair.  The 
mo.st  painstaking  hemo.sta.sis,  the  removal  of  foreign  substances, 
and  the  trimming  of  the  margins  of  lacerated  and  contused  wounds 
are  the  essential  prerequisites  to  bringing  the  wound  surfaces  in  con- 
tact by  mechanical  means. 

In  the  mechanical  treatment  of  wounds  it  is  very  important  to 
make  a  di.stinction  between  a.septic,  suspicious,  and  infected  wounds. 
It  is  only  in  wounds  that  we  have  reason  to  believe  aseptic  that 
we  aim,  by  mechanical  aids  and  with  the  utmo.st  care,  to  bring 
and  hold  in  contact  all  the  anatomic  structures  of  the  wound  for 
the  purpose  of  securing  wound  healing  in  the  shortest  possible 
.space  of  time  and  with  the  best  functional  results.  Such  wounds 
are  the  intentional  wounds  made  by  the  surgeon  in  operating  on 
aseptic  tissues. 


2o6  WOUNDS. 

All  accidental  wounds  must  be  regarded  at  least  in  the  light  of 
suspicious  wounds,  and  are  treated  as  such  according  to  the  nature 
of  the  wound,  the  character  of  the  vulnerating  implement,  the 
structure  of  the  wounded  tissues,  and  the  time  that  has  elapsed 
since  the  injury  was  received  and  the  first  aid  rendered.  In  in- 
fected wounds  the  mechanical  treatment  is  limited  largely  to  efforts 
to  secure  rest  of  the  injured  part  or  organ  by  position,  splints, 
and  bandages.  No  attempt  is  made  to  bring  the  infected  surfaces 
in  close  contact,  as  such  treatment  would  interfere  seriously  with 
the  employment  of  free  drainage  and  antiseptic  solutions,  so  essen- 
tial in  transforming  a  septic  into  an  aseptic  wound. 

Position. — Position  is  an  important  element  in  the  mechanical 
treatment  of  all  wounds.  Whenever  it  can  be  done  without  dis- 
comfort to  the  patient,  the  injured  part  should  always  be  placed  in 
an  elevated  position.  This  diminishes  the  arterial  blood  supply  to 
the  part  and  favors  venous  return,  vascular  conditions  best  calcu- 
lated to  minimize  parenchymatous  bleeding,  tension,  and  pain. 
Position  is  again  employed  in  relaxing  the  tissues  involved  in  the 
injury,  a  part  of  wound  treatment  that  is  particularly  important 
when  tendons,  muscles,  or  nerves  have  been  severed.  A  failure  to 
place  the  limb  in  proper  position  is  often  the  cause  of  undue  ten- 
sion on  the  sutures,  unnecessary  pain,  and  unsatisfactory  healing  of 
the  wound.  In  wounds  over  the  extensor  side  of  the  extremities 
the  limb  must  be  placed  and  held  in  the  extended  position  by 
an  appropriate  mechanical  support  until  the  wound  has  healed. 
An  opposite  course  is  pursued  if  the  wound  involves  the  deep 
structures  on  the  opposite  or  flexor  side.  In  secondary  suturing 
of  tendons,  muscles,  and  nerves,  where  the  diastasis  is  often  great, 
after  vivifying  the  structures  we  wish  to  unite,  accurate  suturing  is 
possible  only  by  securing  the  necessary  degree  of  relaxation  by 
position. 

Suturing. — All  aseptic  incised  wounds  extending  beyond  the 
skin  should  be  sutured.  Asepsis  has  made  this  part  of  the  treat- 
ment of  wounds  almost  imperative.  There  is  no  region  or  tissue 
on  the  surface  of  the  body  which  contraindicates  suturing  of 
wounds  large  enough  to  require  mechanical  treatment  in  approxi- 
mating the  margins.  Asepsis  has  made  the  suture  safe  and  useful. 
Careful  suturing  is  often  a  tedious,  but  ahvays  a  grateful,  task.  The 
surgeon  who  is  careful  and  proficient  in  this  fart  of  Ids  zvork  is  the 
07ie  who  will  achieve  the  best  cosmetic  and  functional  residts.  The 
old-fashioned  interrupted  suture  so  long  relied  upon  almost  ex- 
clusively in  uniting  wounds,  regardless  of  their  depth  and  the 
tissues  involved,  has  now  been  supplied  with  a  most  useful  ally  in 
the  form  of  the  absorbable  buried  or  "  etagen  "  suture. 

The  absorbable  buried  suture  meets  two  important  indications 
in  the  modern  treatment  of  wounds  : 

I.  It  is  of  the  utmost  practical  value,  in  fact  almost  indispens- 
able, in  uniting  anatomic  structures  of  the  same  kind  in  uniting  deep 


SUTURING. 


207 


■wounds  in  which  several  different  anatomic  structures  have  been 
divided. 

2.  Properly  employed,  it  is  the  most  important  agent  in  the  pre- 
vention of  so-called  "  dead  spaces,"  and  consequently  has  accom- 
plished much  in  limiting  the  indications  for  drainage. 

Catgut  is  the  best  material  for  the  buried  suture.  Its  use  is 
indicated  in  all  deep  aseptic  wounds.  Reference  here  will  only  be 
made  to  two  kinds  of  wounds  where  its  employment  furnishes  the 
most  striking  illustrations  of  the  benefits  to  be  derived  from  it. 
Let  us  suppose  that  a  recent  accidental  transverse  wound  above  the 
wrist-joint,  over  the  anterior  surface  of  the  forearm,  requires  sutur- 
ing. Examination  shows  that  the  median  nerve  and  a  number  of 
the  flexor  tendons  have  been  divided.      After  careful  hemostasis  has 


Fig.  III. — Suturing  of  tendons  and  nerves  in  incised  wounds  :     a,   Primary  tendon 
suture  ;  l>,  primary  nerve  suture. 


been  effected  and  the  wound  thoroughly  disinfected,  the  surgeon  pro- 
ceeds to  unite  the  severed  parts  separately  by  the  use  of  the  absorb- 
able buried  suture.  The  ends  of  the  median  nerve  are  found  and 
united  separately  by  two  or  more  catgut  sutures,  using  for  this  pur- 
pose a  round  needle  and  fine  catgut.  The  severed  tendons  are 
treated  in  tiic  same  manner,  using  an  ordinary  round,  curved  sur- 
gical needle  and  somewiiat  coarser  catgut  in  uniting  the  respective 
ends.  The  deep  fascia  is  next  sutured  over  the  united  nerve  and 
tendons  by  inserting  and  tying  a  row  of  binned  sutures.  The  skin 
is  finally  united  in  the  usual  way,  the  dressing  applied,  and  the 
forearm  immobilized  with  the  fingers  and  hands  well  flexed. 

The    next    <jbject-lcsson    is    furnished    by    the    suturing  of  an 
abdominal  woinid,  which  is  done   in   the  following  manner:     The 


208 


WOUNDS. 


requisite  number  of  silkworm-gut  sutures  are  inserted  but  not  tied, 
and  are  made  to  include  all  the  tissues,  except  the  peritoneum. 
The  peritoneum  is  sutured  separately  with  fine  catgut.  Next  the 
fascia  of  the  recti  muscles  is  united  by  a  row  of  coarser  buried  cat- 
gut sutures,  after  which  the  deep  sutures  are  tied  and,  finally,  the 
skin    between    them    is    carefully   united    with    horsehair    sutures. 


Fig.  112. — Suturing  of  deep  fascia. 


Fig.  113. — Suturing  completed. 


Wounds  in  any  other  part  of  the  body  that  are  deep  enough  to 
require  the  use  of  the  buried  suture  are  dealt  with  in  a  similar 
manner,  the  surgeon  always  having  in  view  the  uniting,  by  this 
mechanical  resource,  of  similar  anatomic  structures,  and  in  such  a 
way  as  to  guard  against  the  formation  of  dead  spaces.  If  buried 
sutures  are  used,  it  is  well  to  insert  the  deep  sutures  first,  leaving 
them  untied  until  the  deep  suturing  has  been  completed. 


SUTURING.  209 

Another  important  indication  for  the  employment  of  buried 
sutures  is  presented  by  wounds  of  very  vascular  organs,  when  they 
are  occasionally  employed  as  hemostatic  agents  in  arresting  trou- 
blesome parenchymatous  hemorrhage.  When  employed  for  such  a 
purpose,  the  needle  must  be  round  and  well  curved,  the  catgut  be 
fine,  and  the  sutures  be  placed  close  together. 

Tension  sutures  are  needed  when  it  is  found  difficult  to  bring 
the  wound  surfaces  in  contact  by  the  ordinary  approximation 
sutures.  Coarse  silk  is  the  best  material  for  this  purpose.  From 
one  to  two  inches  are  included  in  the  suture  on  each  side,  and  the 
sutures  are  removed  as  soon  as  they  can  be  dispensed  with,  which 
is  usually  the  case  after  from  the  third  to  the  fifth  day.  The  re- 
tention of  such  sutures  for  too  long  a  time  is  sure  to  result  in  more 
or  less  linear  pressure  necrosis.      Metallic  wire  is  seldom  employed 


Fig.  114. — Hand  and  forearm  dressed  in  proper  position. 

at  the  present  time,  either  as  tension,  buried,  or  approximation 
sutures,  as  it  does  not  present  any  special  advantages  over  other 
nonabsorbable  suture  material,  especially  silkworm  gut.  For  sutur- 
ing the  skin  there  is  no  better  material  than   horsehair. 

Horsehair  can  be  readily  sterilized,  is  elastic,  is  easily  tied,  and 
remains  in  the  ti.ssues  for  weeks  without  giving  rise  to  the  slightest 
irritation.  It  is  the  material  of  choice  in  the  suturing  of  wounds 
made  for  plastic  purposes.  It  is  a  very  common  mistake  to  tie 
the  sutures  too  tightly.  Unneces.sary  tension  must  be  carefully 
avoided,  and  in  tying  the  sutures  some  allowance  must  be  made 
for  more  or  less  swelling  of  the  tissues,  which  often  takes  place 
even  in  aseptic  wounds.  Another  ecjually  prevalent  mistake  is 
made  in  tying  the  sutures  directly  over  the  wound,  where  the  knot 
14 


2IO 


WOUNDS. 


often  interferes  with  the  accurate  coaptation  of  the  skin  underneath 
it  and  unnecessarily  comphcates  the  removal  of  the   suture.      The 


— Straight  surgical  needles.  Fig.  Il6. — Half-curved  surgical  needles. 


suhire  should  akvays  be  tied  near  one  of  the  piinctiires  in  the  skin, 
for  the  reasons  just  mentioned.  The  sutures  must  remain  in  place 
until  the  object  for  which  they  were  employed  has  been  realized — that 

is,  until  the  wound  has 
tinited  sufficiently  to  render 
this  mechanical  aid  super- 
jiiious. 

The  rapidity  with  which 
a  wound  heals  depends  on 
its  size,  the  structure  of  the 
injured  tissues,  and  its  lo- 
cation. The  too  early  re- 
moval of  sutures  is  followed 
by  yielding  of  the  delicate 
scar,  and  their  prolonged 
retention  is  often  attended 
and  followed  by  severe  pain. 
In  superficial  wounds  of 
Fig.  117.— Full  curved  surgical  needles.  Very  vascular  tissue,  such 

as  the  scalp,  lips,  skin  of 
face,  etc.,  their  presence  and  support  become  superfluous  in  the 
course  of  from  three  to  five  days.  The  early  removal  of  the  deep 
sutures  is  especially  desirable  after  operation  for  harelip  and  other 


SUTURING. 


211 


plastic  operations.  In  amputations,  excision  of  the  breast,  perine- 
orrhaphy, abdominal  and  hernial  operations  it  is  not  advisable 
to  remove  them  before  one  or  two  weeks  after  the  operation, 
unless  special  indications  arise.  In  removing  the  suture  the  knot 
should  be  grasped  with  a  toothed  dissecting  forceps,  slight  traction 
made,  the  sharp  point  of  the  scissors  inserted  underneath,  and  the 


Fig.  Il8. — Truax's  automatic  needle-holder. 


Fig.  119. — Abbe's  needle-holder. 


Fig.  120. — Truax's  comljined  needle-holder. 


thread  cut  beneath  the  knot  and  the  puncture  nearest  to  it.  Silk- 
worm gut  is  an  excellent  suturing  material,  but  it  cuts  through 
the  ti.ssues  much  more  readily  than  silk,  and  it  is  for  this  rea.son 
that  I  prefer  the  latter  material  in  operations  for  harelip,  cleft 
palate,  and  for  other  pla.stic  operations.  The  needle-holder  should 
be  employed  only  in  localities  where  the  fingers  can  not  be  used  in 
handling  the  needle.      The    Russian   and   Truax's  needle-holders 


212 


WOUNDS. 


are  the  best   substitutes  for   the  fingers.      In  suturing  superficial 
wounds  the  needles  used  by  saddlers  and  glovers  are  the  best. 

Secondary  suturing  is  frequently  resorted  to  at  the  present 
time,  either  for  the  purpose  of  closing  aseptic  wounds  completely 
after  the  removal  of  the  drain,  or  to  unite  aseptic  granulating  sur- 
faces. In  the  former  case  the  secondary  sutures  are  inserted  at 
the  time  the  operation  is  performed,  their  ends  are  tied,  and  after 
the  removal  of  the  drain,  the  knot  is  cut  and  the  sutures  tied  in  the 
usual  way.  Wounds  thus  treated  will  heal  by  primary  intention 
even  if  the  drain  remains  for  several  days,  provided,  of  course,  that 
they  remain  aseptic.  Suturing  of  granulating  aseptic  wounds  can 
be  done  successfully  in  the  usual  way,  and  whenever  it  is  possible, 
the  sutures  should  be  passed  their  entire  length  well  underneath 
the  granulating  surface.  This  procedure  prevents  injury  to  the 
granulations,  and  the  formation  of  dead  spaces  is  less  likely  to 
occur.  Wounds  thus  united  heal  in  the  same  manner  and  in  the 
same  length  of  time  as  recent  wounds,  but  the  cosmetic  and  func- 
tional results,  for  obvious  reasons,  are  usually  less  satisfactory. 


Fig.  121. — Tension  and  inter- 
rupted sutures. 


Fig.  122. — Continued  suture. 


Fig.  123. — Manner  of 
removing  suture. 


The  bloodless  suture  is  a  very  valuable  mechanical  aid  in 
diminishing  the  size  of  granulating  surfaces.  In  large  granulating 
wounds  it  should  be  made  use  of  as  soon  as  suppuration  is  under 
control.  Its  mechanical  effect  is  most  marked  after  the  wound 
surface  has  become  aseptic.  It  is  made  by  two  strips  of  rubber 
adhesive  plaster,  each  of  which  is  fastened  with  one  end  to  the 
skin  some  distance  from  the  granulating  border.  The  part  of  the 
piece  of  plaster  to  give  the  necessary  hold  on  the  skin  is  cut  into 
narrow  strips,  which  are  applied  in  the  form  of  a  fan  (Fig.  125). 
The  hold  on  the  skin  can  be  materially  increased  by  applying  collo- 
dion and  a  thin  film  of  absorbent  cotton  over  the  fan-like  expansion. 
The  wound  is  protected  with  strips  of  aseptic  gutta-percha  or  pro- 
tective silk,  over  which  a  dry,  aseptic,  small  gauze  compress  is 
applied.  The  wound  margins  are  then  approximated  as  near  as 
possible  by  hand  pressure,  and  the  two  strips  of  adhesive  plaster 
are  fastened  together  over  the  gauze  dressing  with  a  safety-pin. 
The  traction  can  be  regulated  from  day  to  day.  In  large  wounds 
several  pairs  of  adhesive  strips  may  be  employed. 

The  bloodless  suture,  used  in  the  manner  described,  not  only 
constitutes  a  valuable  mechanical  aid  in  diminishing  the  healing 


FIXATION    DRESSINGS. 


213 


surfaces,  but  it  also,  at  the  same  time,  secures  compression,  so  im- 
portant an  element  in  expediting  cicatrization  and  epidermization. 
This  mechanical  support  is  of  special  value  in  hastening  the  heal- 
ing of  wounds  that  can  not  be  sutured  after  excision  of  the  breast, 
and  in  cases  of  retraction  of  the  flaps  after  amputation. 

Fixation  Dressings. — The  immobilization  of  the  injured  tis- 
sues is  a  ver\-  essential  part  of  wound  treatment,  as  the  wound  is 
thus  placed  at  rest,  a  very  important  condition  to  a  satisfactory- 
process  of  healing.  The  necessary  degree  of  fixation  can  often  be 
attained  by  the  dressing,  but  in  large  wounds  of  the  neck,  chest, 
and  extremities  some  sort  of  a  fixation  dressing  must  be  used  to 
immobilize  the  injured  part.  Splints  are  not  used  so  often  as  they 
should  be  in  the  after-treatment  of  wounds  of  the  soft  parts.  Every 
amputation  stump  should  be  immobilized  by  a  well-fitting  and  well- 


Fig.  124. 


-Bloodless  suture  :    a.  Showing  shape  and  application  of  strips  of  adhesive 
plaster ;  b,  dressing  applied  and  held  in  place  by  bloodless  suture. 


padded  hollow  splint.  It  is  an  important  constituent  part  of  the 
first  dressing,  as  by  its  use  painful  muscular  twitchings  and  undue 
retraction  of  the  flaps  are  prevented.  In  large  wounds  of  the  neck 
a  i^w  turns  of  the  plaster-of- Paris  bandage  over  the  dressing  will 
secure,  in  a  satisfactory  manner,  fixation  and  rest  of  the  injured 
part.  Broad  strips  of  adhesive-plaster  binder  or  roller  bandage  are 
relied  upon  in  immobilizing  the  chest  and  abdomen.  In  woiuids  of 
the  extremities  the  plaster-of-Paris  or  a  well-fitting  anterior  or 
posterior  splint  is  usually  employed  for  securing  rest  for  the  wound. 
The  mechanical  support  should  be  continued  until  the  process 
of  healing  has  been  completed  :  in  some  cases  a  considerable  length 
of  time  after  the  sutures  have  been  removed,  as  a  too  early  resump- 
tion of  the  use  of  the  injured  part  not  infrequently  impairs  what 
othcrwi.se  might  have  been  an  ideal  result. 


214  WOUNDS. 

Compression. — A  moderate  degree  of  equable,  uninterrupted, 
prolonged  compression  is  a  mechanical  condition  favorable  to  speedy 
satisfactory  healing  of  an  aseptic  zvound.  Compression  properly 
employed  does  much  in  aiding  the  sutures  in  bringing  and  holding 
the  wound  surfaces  in  contact.  Moreover,  at  the  same  time  it  is 
well  calculated  to  guard  against  the  accumulation  of  primary  wound 
secretion,  thereby  preventing  swelling  and  tension.  It  also  con- 
tributes much  in  securing  rest  for  the  wound. 

Compression,  as  practised  at  the  present  day,  is  made  by  the 
hygroscopic  elastic  aseptic  dressing,  made  of  gauze  and  cotton,  and 
held  in  place  by  a  bandage,  strips  of  adhesive  plaster,  or  by  both. 
The  bandage  for  the  fixation  of  such  a  dressing  is  made  of  several 
layers  of  aseptic  hygroscopic  gauze,  as  it  is  more  elastic  than  the 
ordinary  muslin  or  cambric  roller,  and  hence  better  calculated  to 
maintain  the  necessary  degree  of  elastic  pressure. 

Drainage. — By  drainage  is  meant  the  employment  of  such 
physicomechanical  measures  as  will  prevent  the  accumulation  of 
fluids  in  a  wound  or  cavity  the  seat  of  a  pathologic  effusion  or 
extravasation.  Drainage  is  a  necessary  evil  in  the  treatment  of 
recent  aseptic  wounds  in  which  accumulation  of  blood  or  serum  is 
likely  to  occur  to  an  extent  that  will  interfere  with  mechanical 
conditions  necessary  to  insure  satisfactory  healing — that  is,  in  cases 
in  which  the  hemostasis  is  incomplete,  or  the  mechanical  aids  fail 
in  effecting  and  maintaining,  for  the  necessary  length  of  time, 
uninterrupted  coaptation  between  the  wound  surfaces.  Drainage 
is  always  indicated  in  the  treatment  of  septic  wounds,  and  after 
removal,  by  operative  interference,  of  liquid  infected  products  from 
any  of  the  cavities  of  the  body,  preformed  or  pathologic. 

Drainage  of  a  recent  zvound  is  an  open  confession  of  our  present 
impel  feet  means  of  securing  and  maintaining  absolute  asepsis.  The 
surgeons  zuho  are  most  careful  in  their  aseptic  precatitions  and  zvound 
treatment  drain  least  frequently ,  zvhile  others  zvlio  are  hasty  in  their 
zvork,  and  especially  those  zvlio  are  obliged  to  operate  zvith  the  aid  of 
careless  or  inexperienced  assistants,  must  necessarily  drain  often. 
Drainage  is  and  zvill  remain  a  common  practice  in  the  treatment  of 
accidental  zvounds  and  in  the  performance  of  emergency  operations. 
Accidental  wounds  are  always  infected  wounds  before  the  patients 
come  under  the  care  of  the  surgeon.  It  is  in  such  cases,  too,  that 
the  means  of  procuring  asepsis  are  often  limited,  and  the  assistance 
unreliable. 

Emergency  operations  are  operations  which  must  be  performed 
quickly,  and  consequently  the  haste  with  which  preparations  must 
be  made  often  precludes  the  bringing  into  effect  of  the  necessary 
aseptic  precautions.  The  rule  still  holds  good  :  "  When  in  doubt, 
drain  "  (Tait).  Good  judgment  and  careful  consideration  of  condi- 
tions and  circumstances  are  frequently  required  when  the  surgeon 
is  to  decide  the  important  matter  whether  or  not  the  safety  of  the 
patient  requires  drainage  of  the  wound.      Very  often  the  life  of  the 


DRAINAGE.  215 

patient  depends  on  the  course  he  adopts.  While  opinions  may  differ 
in  7'egard  to  the  necessity  of  drainage  in  recent  ivounds  in  zvell- 
eqnippcd  operating  theaters,  there  can  be  no  donbt  that  in  emergency 
practice,  when  any  question  arises  as  to  the  propriety  of  establishing 
drainage,  the  patient  should  be  given  the  benefit  of  the  doubt  and 
drainage  be  employed.  To  decide  when  and  how  to  drain  consti- 
tutes one  of  the  most  important  items  in  the  mechanical  treatment 
of  wounds. 

The  present  methods  of  drainage  consist  of :  ( i )  Patency  of 
wound  ;  (2)  tubular  drainage  ;  (3)  capillary  drainage. 

Infected,  contused,  and  lacerated  wounds  are  best  drained  by 
leaving  them  open,  applying  the  antiseptic  or  aseptic  dressing 
directly  to  the  wound  surface — that  is,  by  resorting  to  the  open- 
wound  treatment  under  the  antiseptic  or  aseptic  compress.  If  the 
wound  is  very  irregular,  the  gauze  should  reach  the  deeper  re- 
cesses, so  as  to  remove  the  wound  fluids  by  capillary  action.  In- 
fected and  contused  wounds  are  never  sutured,  but  other  mechani- 
cal aids  are  often  employed  to  diminish  the  wound  surface,  such 
as  bandages,  strips  of  adhesive  plaster,  and  splints. 

The   tubular  drains   are  made  of  rubber,  glass,   or  decalcified 


Fig.  125. — Antiseptic  soft-rubber  drainage-tube  bottle. 

bone.  Neuber  introduced  the  absorbable  tubular  drain  of  decalci- 
fied bone  for  the  purpose  of  obviating  the  necessity  of  an  earl)^ 
change  of  dressing  in  order  to  remove  the  drain.  He  used  tubes 
made  of  the  compacta  of  the  long  bones  of  cattle.  Trendelenburg 
and  MacEvven  made  the  tubes  of  the  decalcified  shafts  of  the  long 
bones  of  birds  ;  and  Watson  Cheyne  made  absorbable  tubes  of 
catgut.  The  experience  with  these  tubes  did  not  meet  the  expecta- 
tions entertained,  and  they  are  seldom  emplo\'ed  at  the  present  time. 
Glass  drains  retain  their  reputation  for  draining  the  peritoneal 
and  pelvic  cavities.  The  present  manner  of  using  them  is  to  pack 
the  lumen  of  the  tube  lightly  with  a  strip  of  iodoform  gauze  or 
aseptic  wicking,  thus  combining  tubular  with  capillary  drainage. 
For  ordinary  purposes,  and  especially  in  emergency  work,  the  rub- 
ber drain  is  the  one  that  deserves  the  preference.  The  rubber 
tubing  can  be  sterilized  by  boiling  in  soda  solution,  and  is  kept 
ready  for  use  in  any  of  the  strong  antiseptic  solutions.  To  be 
efficient  it  must  be  well  fenestrated.  The  oj)enings  should  be  oval, 
and  never  wider  than  one-fourth  of  the  circumference  of  the  tube. 
The  tube  must  be  ample  in  size.  It  is  a  very  common  mistake  to 
use  tubes  that  are  too  small.  In  large  wounds  several  drains  may 
be  required.      The  drain  should  always  be  placed  in  such  a  manner 


2l6  WOUNDS. 

as  to  drain  the  most  dependent  part  of  the  wound  cavity.  I 
seldom  drain  through  the  incision,  preferring  to  make  a  sepa- 
rate small  incision  at  the  point  where  drainage  will  be  rnost  effi- 
cient. For  instance,  after  excision  of  the  breast  the  buttonhole 
for  the  drain  is  made  at  the  most  dependent  part  of  the  wound, 
behind  the  line  of  suturing  ;  in  amputations  at  the  base  of  the 
posterior  flap,  in  temporary  resection  of  the  skull,  in  the  center  and 
base  of  the  flap. 

Every  drain  must  be  secured  on  the  surface  of  the  body  with  a 
safety-pin,  so  that  the  drain  will  never  find  its  way  beyond  the  sight 
and  reach  of  the  surgeon.  This  injunction  may  appear  superfluous, 
but  I  have  personal  knowledge  of  a  number  of  cases  in  which 
drains  were  lost  in  the  wound  or  cavity  that  it  was  intended  to 
drain.  Such  accidents  will  not  occur  in  the  practice  of  the  care- 
ful physician  or  surgeon.  The  drain  must  correspond  in  length 
to  the  cavity  it  is  expected  to  drain,  and  should  never  project 
any  considerable  distance  beyond  the  surface  of  the  skin.  If 
the  drain  is  too  long,  it  becomes  flexed  and  almost  useless  as  a 
drain  ;  or  it  may  become  bent  or  compressed  by  the  dressing,  causing 
a  mechanical  obstruction  that  interferes  with  the  free  escape  of  the 
wound  secretions  into  the  absorbent  dressing.  The  drain  must 
remain  as  long  as  there  is  anything  to  drain  from  the  wound  or 
cavity — that  is,  until  the  wound  is  dry  or  the  cavity  has  ceased  to 
discharge.  In  recent  wounds  drainage  can  usually  be  dispensed 
with  after  from  three  to  five  days.  If  at  this  time  the  wound  secre- 
tions have  not  ceased  to  flow,  the  drain  is  removed,  cleansed, 
shortened,  and  reinserted.  A  scanty  wound  secretion  is  always  a 
good  indicatio)i  of  the  aseptic  condition  of  the  ivound,  zvhile  a  profuse 
and  prolonged  discharge  very  often  vieans  the  reverse.  As  every 
change  of  dressing  is  always  attended  by  more  or  less  risk  of  wound 
infection,  drains  shoidd  never  be  removed  unnecessarily.  An  early 
removal  of  the  tubular  drain  may  become  necessary  in  case  its 
lumen,  as  so  often  happens,  becomes  blocked  by  a  blood-clot.  The 
blocking  of  the  tubular  drain  from  this  cause  is  one  of  the  great 
objections  to  its  use,  but  as  we  have  no  better  substitute  open  to 
fewer  objections,  such  an  occurrence  must  be  looked  for,  and  when 
found,  must  receive  prompt  attention.  In  draining  the  abdominal 
cavity  I  have  been  for  a  long  time  in  the  habit  of  wrapping  a  thin 
layer  of  iodoform  gauze  around  the  drain,  for  the  double  purpose 
of  protecting  the  intestine  against  harmful  pressure  and  to  increase 
drainage  by  adding  a  capillary  to  the  tubular  drain. 

In  establishing  through  tubular  drainage,  the  end  of  the  drain 
is  grasped  transversely  with  the  forceps,  by  the  aid  of  which  the 
counteropening  is  made.  Both  ends  of  the  drain,  cut  short  to  the 
skin,  must  be  secured  with  safety-pins.  As  soon  as  the  indications 
for  through  drainage  have  been  met,  the  drain  is  removed  and  each 
opening  drained  separately. 

In    cases  in  which   only   a  small    quantity   of  primary   wound 


DRAINAGE. 


217 


Fig.  126. — Murphy's  drainage-tubes. 


secretion  is  expected,  the  capillary  drain  is  often  substituted  for  the 
tubular  drain.      The   materials   that  have   been    used    most  exten- 
sively  for   this   purpose   are   gauze,  catgut,   glass-wool  (Kiimmel), 
horsehair,    silk   threads, 
and  wicking. 

Capillary  drainage  is 
only  adapted  to  the  re- 
moval of  primary  wound 
fluids  ;  it  is  often  worse 
than  useless  in  draining 
suppurating  wounds  and 
abscess  cavities.  The 
Mikulicz  drain  is  a  good 

form  of  the  gauze  capillary  drain.  By  using  a  bag  of  gauze  for  the 
tampon,  in  the  manner  described  in  the  chapter  on  Hemostasis,  it  is 
impossible  to  lose  fragments  of  gauze  in  the  wound.  If  the  typical 
Mikulicz  drain  is  not  used,  the  gauze  drain  should  always  be  made 
of  one  piece,  which  is  fastened  on  the  surface  by  a  safety-pin.  An 
excellent  gauze  drain  can  be  made  by  surrounding  it  with  a  piece  of 
protective  silk,  perforated  at  numerous  points,  and  which  is  included 
in  the  pin  in  fixing  the  capillary  drain.  A  bundle  of  catgut  consti- 
tutes an  excellent  capillary  drain  and  possesses  the  advantage  of 
being  absorbable,  making  it  unnecessaiy  to  change  the  dressing 
until  the  wound  is  healed.  The  capillary  absorbable  drain  is  fre- 
quently employed  in  operations  on  the  skull  and  on  tubercular  joints. 
A  piece  of  aseptic  wicking  or  a  small  bundle  of  horsehair  or  silk 
threads  are  excellent  capillary  drains  and  are  frequently  utilized  in 
draining  small  wounds  requiring  a  short  time  for  drainage.     It  is  in 

cases  of  wounds  that  re- 
quire drainage  for  a  short 
time  that  secondary  closure 
of  the  drainage  opening  by 
secondary  suturing  proves 
so  useful  in  securing 
speedy  healing  of  the 
wound  throughout.  Tub- 
ular drainage  is  always 
necessary  in  draining  sup- 
purating cavities,  while 
suppurating  wounds  are 
best  dealt  with  by  avoid- 
ing suturing  or  by  removal  of  the  sutures  in  the  event  of  suppura- 
tion setting  in,  relying  mainly  on  a  large  opening  or  openings  \x\ 
securing  efficient  drainage  and  in  facilitating  the  antiseptic  treat- 
ment by  furnishing  free  access  to  the  suppurating  surfaces  for  the 
employment  of  antiseptic  solutions. 


Fig.  127. — Keitli's  curved  clraiiiage-tube. 


*5  boo  d~r} 


U:I-m'I*.!.I 


Fig.  128. — Tail's  drainage-tube. 


CHAPTER    VII. 

GUNSHOT  WOUNDS. 

The  effects  of  the  modern  small-caliber  bullet  on  the  bones 
and  soft  tissues  of  the  body  have  been  made  the  subject  of  ex- 
tended experimental  research  by  Bruns,  Kocher,  Helferich,  Griffith, 
La  Garde,  A.  C.  Girard,  and  others,  but  as  yet  no  uniform  con- 
clusions have  been  reached.  The  effects  on  the  cadaver  are  not 
always  the  same  as  are  those  on  the  living  body.  Range  and 
structure  of  the  tissues  greatly  influence  the  nature  of  the  wound. 
Bones  are  extensively  comminuted  if  the  missile  is  fired  within  a 
distance  of  500  yards  ;  a  clean  perforation  with  little  or  no  splin- 
tering is  made  if  fired  within  the  next  500  yards,  and  beyond 
this  range  comminution  is  again  almost  a  constant  result.  Our 
recent  experience  in  Cuba,  which  embraced  nearly  fourteen  hun- 
dred wounded,  and  in  Porto  Rico,  where  the  number  of  wounded 
did  not  exceed  fifty,  showed  that  in  recent  cases  the  small  tubular 
wound  made  by  the  Mauser  bullet  was  surrounded  by  a  narrow 
zone  of  contused  tissue,  and  the  wound  space  itself  filled  with 
either  liquid  or  coagulated  blood.  A  few  days  later  the  wound 
itself  was  found  surrounded  by  an  area  of  suggillation,  which 
varied  in  extent  according  to  the  nature  of  the  tissues  and  the 
amount  of  extravasation.  In  cases  in  which  the  bullet  passed 
through  the  tissues  some  distance,  and  far  from  the  surface  of  the 
skin,  the  location  and  direction  of  the  wound  canal  were  indicated 
by  discoloration  of  the  skin  a  few  days  after  the  injury  occurred. 

In  a  number  of  cases  of  aseptic  wounds  in  which  the  bullet 
had  lodged  in  the  tissues  and  was  removed  a  week  or  ten  days 
later,  I  had  an  opportunity  to  study  the  remoter  effects  of  the  in- 
jury on  the  tissues.  In  all  cases  the  swelling  of  the  tissues  at  this 
time  had  almost  or  entirely  obliterated  the  tubular  wound,  the  loca- 
tion of  which  was  indicated  by  a  dark  discoloration,  parenchyma- 
tous extravasation,  remains  of  fluid  or  coagulated  blood,  and  a 
limited  area  of  edema  and  infiltration.  These  conditions  served  as 
useful  guides  in  following  the  course  of  the  bullet.  The  bullet 
itself  was  usually  found  loose  in  a  small  cavity  filled  with  liquid 
blood  or  bloody  serum,  while  a  more  extensive  zone  of  infiltration 
indicated  the  primary  stage  of  encapsulation.  I  have  no  further 
doubt  but  that  the  new  bullet  will  become  encapsulated  and 
remain  harmless  in  the  tissues  as  readily  as  or  more  so  than  the 
old-fashioned  leaden  bullet.  Through  the  courtesy  of  Major  A. 
C.  Girard,  U.  S.  A.,  I  had  an  opportunity  to  examine  a  number  of 
such  cases  in  the  military  hospital  at  the  Presidio,  San  Francisco. 

218 


GUNSHOT    WOUNDS. 


219 


Among  them  was  a  soldier  recently  returned  from  Manila,  who  was 
carrying  a  Mauser  bullet  in  his  pelvis,  lodged  on  the  left  side  of 
the  prostate  gland,  and  which  could  be  distinctly  felt  through  the 
rectum.  Although  the  bullet  entered  the  posterior  surface  of  the 
left  thigh,  and  while  the  soldier  was  in  a  sitting  position,  finally 
becoming  arrested  in  its  course  in  this  locality,  the  patient  never 
suffered  to  any  extent  from  the  injury.  The  bullet  was  well  en- 
capsulated but  slightly  movable,  the  conic  end  corresponding  with 
the  upper,  and  the  blunt  end  with  the  lower,  border  of  the  pros- 
tate. No  pain  or  tenderness  were  present  on  pressure.  The  total 
absence  of  symptoms  prompted  me  to  advise  against  its  removal. 
The  absence  of  any  symptoms  was  somewhat  remarkable,  consid- 
ering the  location  of  the  bullet  and  its  close  proximity  to  the  rectum, 
always  a  fruitful  source  of  infection  by  the  bacillus  coli  communis. 

Among  the  wounded  of  Cuba,  in  isolated  cases  late  suppura- 
tion at  the  seat  of  the  bullet  resulted  in  the  formation  of  a  circum- 
scribed abscess,  a  complication  which  aided  the  surgeons  in  locat- 
ing and  removing  the  missile.  It  was 
a  surprise  to  us  all  to  find  that  in 
more  than  10  per  cent,  of  all  the 
wounded  the  bullet  was  found  lodged 
in  the  tissues,  a  vastly  greater  number 
than  we  had  any  reason  to  expect. 
The  reason  for  this  became  apparent 
when  we  began  to  study  the  condition 
of  some  of  the  bullets  removed.  A 
large  proportion  of  the  extracted  bul- 
lets were  found  deformed,  showing 
that  they  were  deflected  bullets  that 
had  struck  a  hard  object  or  passed 
through  a  resisting  medium  before 
they  reached  the  object  for  which  they  were  intended, 
upon  which  the  battles  were  fought  is  stony  and  covered  with  trees 
and  thick  underbrush,  furnishing  the  most  favorable  conditions  for 
deflection  of  the  bullets.  Some  of  the  firing  was  done  at  very  long 
range,  so  that  occasionally  a  sj^ent  ball  was  found  in  the  soft  tissues, 
without  having  injured  the  bones.  Such  a  bullet  is  shown  in  figure 
129.  The  bullet  is  a  nickel-encased  Mau.ser  projectile  of  natural 
size  ;  the  jacket  is  perfect,  and  the  bullet  was  removed  from  behind 
the  tibia,  about  four  inches  above  the  ankle-joint.  It  entered  the 
calf  f)f  the  leg  below  the  popliteal  Sjjacc.  and  never  touched  the 
bone. 

I'^'gure  130  represents  the  same  kind  of  a  bullet  ;  the  ])oint  is 
flattened  and  mushroomed.  The  bullet,  which  was  removed  from 
the  head  of  the  tibia,  was  undoubtedly  fired  from  a  great  distance, 
and  the  deformation  was  made  by  the  resisting  bone. 

iMgure  131  exhibits  a  nickel-clad  bullet  very  much  deformed. 
It  was  found   lodged   in  the   deep  ti.ssues  of  the  thigh,  al)out  two 


Fig.  129. — 

Mauser     bullet, 
natural  size. 


Fig.  130.— 
Mauser  bullet, 
slightly  d  e  - 
formed. 

The  Gfi'ound 


220 


GUNSHOT    WOUNDS. 


Fig.  131. — Mauser  bullets  much  deformed. 


inches  from  the  wound  of  entrance,  sHghtly  overlapping  the  femur 
near  the  middle  of  the  shaft.  The  bullet  evidently  struck  a  stone 
behind  its  point,  and  was  deflected  before  it  entered  the  body.      It 

was  much  flattened  and  curved. 
a  shows  the  convex  side,  the 
point  of  bullet  and  the  jacket 
being  perfect.  b  exhibits  the 
edge  and  curve  of  the  bullet. 
c  shows  the  concave  side,  ex- 
hibiting a  wide  rent  in  the 
jacket,  indicated  by  the  dotted 
lines,  the  lead  being  exposed 
between  them. 

Figure  132  illustrates  the  de- 
formity of  a  large-caliber  brass- 
clad  bullet.  As  the  bullet  was  removed  from  the  soft  tissues  from 
a  wound  without  bone  injury,  the  deformity  must  have  been  caused 
outside  of  the  body.  The  bullet  is  flattened  on  one  side,  from  a 
point  near  the  tip  to  near  the  base  of  the  leaden  core. 

As  the  Spanish  army  is  armed  exclusively  with  the  Mauser 
rifle,  the  weapon  from  which  this  bullet  was  fired  must  have  been 
in  the  hands  of  a  volunteer  or  possibly  of  a  Cuban. 

The  extent  of  injury  from  bullets  to  any  of  the  hollow  viscera 
of  the  body  is  greatly  influenced  by  their  contents.  The  explosive 
effect  is  marked  when  they  contain  much  fluid,  and  simple  pene- 
trating wounds  may  be  expected  when  they  are  practically  empty. 
These  facts  are  of  special  importance  in  cases  of  visceral  injuries  of 
the  gastro-intestinal  canal 
in  penetrating  wounds  of 
the  abdomen.  A  bullet 
passing  through  the  body 
lengthwise,  as  is  so  often 
the  case  when  the  soldier 
is  in  the  prone  position  at 
the  moment  the  injury  is 
inflicted,  may  make  a  num- 
ber of  wounds,  implicating 
different  regions  of  the 
body.  I  have  seen  more 
than  one  instance  in  which 
three  wounds  of  entrance 
and  of  exit  were  inflicted 
by  the  same  bullet. 

Diagnosis. — The  diagnosis  in  gunshot  wounds  includes,  besides 
establishing  the  existence  of  the  injury,  the  interpretation  of  the 
existence,  nature,  and  number  of  visceral  lesions  in  the  line  traversed 
by  the  bullet.  The  latter  part  of  the  diagnostic  work  is  necessarily 
uncertain  when  the  bullet  is  lodged  in  the  body.      This  is  the  case 


Fig.  1 32. — Deformation  of  large-caliber  brass- 
clad  bullets  :  a  Exhibits  the  convex  side  ;  behind 
the  last  convex  transverse  groove  the  lead  is  ex- 
posed ;  b  illustrates  the  flattened  sides  of  the 
dotted  lines  ;  c  shows  the  margin  of  the  bullet 
and  the  location  and  extent  of  the  flattening. 


DIAGNOSIS. 


221 


when  only  one  wound  can  be  found,  which  is  the  surest  indication 
that  the  bullet  is  lodged  somewhere  in  the  body.  In  such  instances 
it  is  difficult  and  often  impossible  to  ascertain  the  direction  and 
length  of  the  wound  canal,  and  consequently  to  determine  the 
anatomic  character  of  the  visceral  lesions.  The  existence  of  two 
wounds  is  almost  positive  evidence  that  the  bullet  has  traversed  the 
body,  in  which  event  a  straight  line  from  the  wound  of  entrance  to 
the  wound  of  exit  will  indicate  the  organs  implicated  in  the  injury. 
The  existence  of  more  than  two  wounds  in  a  straight  line  is  almost 
positive  evidence  that  they  were  inflicted  by  the  same  bullet. 

Probino-  of  the  wound  for  diagnostic  purposes  has  become,  with 
very  few  exceptions,  an  unjustifiable  procedure.  My  bullet  probe 
consists  of  a  soft  metal  flexible  rod,  jointed  in  the  center  and  tipped 
at  each  end  with  a  porcelain  bulb,  one  No.  22  and  the  other  No. 
38,  French  scale. 

Heretofore,  in  the  construction  of  probes  with  this  class  of  tips, 


Pig    133. — Deformation  of  leaden  bullets  (natural  size)  (Seydel). 


Fig.  134. — Deformation  of  small-caliber  jacketed  bullets  (after  Bruns). 

the  porcelain  portion  has  been  attached  to  the  rod  by  boring  or 
molding  a  hole  in  the  former  and  fastening  the  two  parts  together 
with  cement.  This  procedure  resulted  in  many  accidents,  either 
from  the  detachment  or  the  breaking  of  the  porcelain  bulb.  After 
much  experimenting  a  probe  was  produced  with  an  opening  entirely 
through  the  porcelain  tip,  the  rod  passing  through  the  latter,  its 
distal  end  being  riveted  upon  the  outer  border  of  the  bulb.  This 
method  of  construction  renders  this  probe  perfectly  .safe,  without 
in  the  lea.st  impairing  its  diagnostic  value.  The  full  length  of  the 
probe  is  nine  inches. 

In  the  ca.ses  in  wiiich  such  a  course  is  indicated,  the  size  of  the 
probe  should  correspond  as  nearly  as  pos.sible  to  the  si/.e  of  the  lumen 
of  the  track  made  by  the  bullet.  The  modern  small-caliber  bullet 
will  render  a  resort  to  the  bullet  probe  much  less  frequent  than  the 


222 


GUNSHOT    WOUNDS. 


bullets  used  in  the  wars  of  the  past.  Owing  to  its  greater  velocity  and 
power  of  penetration,  it  will  pass  through  the  different  parts  of  the 
body,  regardless  of  the  resistance  offered  by  the  osseous  structures 
at  a  distance  intended  for  shooting  to  kill.  In  the  presence  of  a 
wound  of  entrance  and  of  exit,  the  use  of  the  probe  is  of  no 
diagnostic  value  whatever,  as  an  exploration  of  this  kind  adds 
nothing  to  our  knowledge  of  the  nature  of  the  injury  and  frequently 
becomes  a  direct  source  of  infection  or  a  cause  of  renewal  of  hem- 
orrhage. Search  for  the  bullet  under  strict  aseptic  precautions  is 
occasionally  a  justifiable  diagnostic  procedure  in  gunshot  fractures 
and  in  penetrating  wounds  of  the  cranium  and  joints.  It  is  abso- 
lutely contraindicated  in  penetrating  wounds  of  the  chest  and 
abdomen.  In  bullet  wounds  of  the  soft  parts  an  attempt  in  this 
direction  is  warranted  when  the  surgeon  has  reason  to  believe  that 
the  bullet  is  located  in  a  place  favorable  to  its  safe  removal.  Prob- 
ing for  bullets,  on  the  zvhole,  has  done  infinitely  more  harm  than  good 


Fig.  135. — Nekton's  bullet  probe. 


Fig.  136. — Senn's  bullet  probe. 


^ig-  137- — Fluhrer's  aluminum  gravitation  probe  (natural  size,  except  the  length,  which 

is  twelve  inches). 


in  the  past,  and  the  livnts  of  the  indications  for  this  procedure  will  be 
greatly  reduced  in  the  future. 

If  the  location  and  nature  of  the  injury  make  a  search  for  the 
bullet  and  an  attempt  at  its  removal  necessary,  the  exploration 
should  be  made  systematically  and  under  the  strictest  aseptic  pre- 
cautions. 

The  metal  jacket  of  the  modern  bullet  has  largely  detracted 
from  the  diagnostic  value  of  the  famous  Nelaton  probe,  and  has 
made  the  equally  famous  American  bullet  forceps  obsolete  as  an 
instrument  for  extraction.  The  porcelain  bulb  of  Nelaton's  probe 
will,  however,  answer  a  useful  purpose  in  following  the  track  made 
by  the  bullet  and  in  demonstrating  the  presence  of  foreign  sub- 
stances in  the  soft  tissues.  The  porcelain  bulb  of  the  ordinary 
Nelaton's  bullet  probe  is  too  small,  especially  in  searching  for 
bullets  of  large  caliber.  It  is  much  easier  to  follow  the  tubular 
wound  with  a  probe  the  porcelain  bulb  of  which  approximately 
corresponds  in  size  to  that  of  the  bullet.     As  in  instrumentation  of 


DIAGNOSIS. 


223 


the  urethra,  a  false  passage  is  more  likely  to  be  made  with  a  small 
than  \\  ith  a  large  instrument. 

Ill  searching  for  bullets  it  is  of  the  greatest  importance  to  bring  the 
parts  and  tissues  of  the  body  as  nearly  as  possible  in  the  exact  posi- 
tion they  occupied  at  the  moment  the  injury  was  received. 

That  no  more  force  should  be  employed  in  using  the  bullet 
probe  than  in  passing  a  catheter  is  simply  to  repeat  a  cardinal  rule 
to  which  there  should  be  no  exceptions.  Skill  in  the  delicate  ma- 
nipulation of  the  instrument,  patience,  and  persev^erance  will  accom- 
plish more  than  force  in  these  cases.  In  exploring  wounds  of  the 
brain  Fluhrer's  aluminum  gravitation  probe  (Fig.  137)  is  the 
proper  instrument 
to  use.  By  plac- 
ing the  head  in 
such  a  position  as 
to  make  the  tubu- 
lar wound  perpen- 
dicular, the  probe, 
by  its  own  weight, 
glides  along  the 
track  until  the 
bullet  or  the  op- 
posite side  of  the 
skull  is  reached. 
The  latter  is  the 
case  if  the  bullet 
has  become  de- 
flected from  that 
point,  as  was  the 
case  in  a  patient 
operated  upon  by 
Fluhrer.  He  then 
made  a  counter- 
opening  in  the 
skull,  and  fol- 
lowed again  in  the 
same  manner  the 
track  made  by  the 

deflected   bullet,  finally  succeeding  in   finding  and  extracting  the 
mi.ssile. 

Bullets  that  "can  be  felt  under  the  skin  opposite  the  wound  of 
entrance  are  extracted  without  exploration  of  the  wound  canal. 

The  use  of  the  probe  as  a  diagnostic  instrument  in  locating 
bullets  in  modern  military  service  has  been  almost  entirely  super- 
.sedcd  by  dissection  and  the  employment  of  the  Rontgen  ray.  If, 
from  the  nature  of  the  injury  and  the  .symptoms  presented,  the  bullet 
is  believed  to  lodge  in  a  part  of  the  body  readily  and  safely  accessible 
to   the  knife,  and   it  is  deemed  advisable   and  expedient  to  remove 


Fig.  138. — Bird  shot  embedded  for  several  years  in  and 
around  the  ankle-joint. 


224 


GUNSHOT    WOUNDS. 


it,  this  can  often  be  done  more  expeditiously  and  with  a  greater 
degree  of  certainty  by  enlarging,  under  strict  aseptic  precautions, 
the  track  made  by  the  bullet,  than  by  relying  on  the  probe  in  finding, 
and  on  the  forceps  in  extracting,  the  bullet.  If,  as  is  often  the 
case,  the  whereabouts  of  the  bullet  is  not  known,  its  presence  and 
exact  location  can  be  determined  without  any  pain  or  any  additional 
risk  to  the  patient,  by  the  use  of  the  X-ray.  It  becomes  apparent, 
therefore,  that  no  attempts  should  ever  be  made  to  find  or  remove 


Fig.  139. — Leaden  bullet  encysted  in  the  chest  below  the  clavicle  for  five  years. 


bullets  on  the  battle-field,  as  this  part  of  the  surgeon's  work,  if  it  is 
indicated  at  all,  must  be  reserved  until  the  surgeon  can  avail  him- 
self of  the  modern  diagnostic  resources  and  facilities  for  asepsis 
which  can  only  be  furnished  by  a  well-equipped  hospital. 

All  the  bullets  removed  on  board  of  the  hospital  ship  Relief 
were  located  by  the  Rontgen  ray.  Dr.  Gray,  an  expert  in  ski- 
agraphy, who  had  charge  of  the  scientific  work  of  the  floating  hos- 
pital, was  of  the  greatest  service  to  the  surgeons  in  enabling  them 
to  locate  bullets  and  in  guiding  them  as  to  the  advisability  of  un- 
dertaking an  operation  for  their  removal.      His  large  collection  of 


PROGNOSIS. 


225 


skiagraphic  pictures  will  also  throw  a  flood  of  new  light  on  the 
effects  of  the  small-caliber  bullet  on  the  different  bones  of  the  body. 
The  skiagraph  has  enabled  us  to  diagnosticate  the  existence  or  the 
absence  of  fracture  in  a  large  number  of  doubtful  cases  in  which  we 
had  to  depend  exclusively  on  this  diagnostic  resource. 

In  fractures  in  close  proximity  to  joints  the  X-ray  has  been 
of  the  greatest  value  in  ascertaining  whether  or  not  the  fracture 
extended  into  the  joint.  In  one  case  of  gunshot  wound  at  the 
base  of  the  thigh,  in  which  the  bullet  passed  in  the  direction 
of  the  trochanteric  portion  of  the  femur,  opinions  were  at  vari- 
ance concerning  the  extent  of  injury  to  the  bone.  Some  of 
the  surgeons  made  a  diagnosis  of  fracture,  while  others  contended 
that  there  was  no  fracture,  but  believed  that  the  bullet  had  made  a 
deep  groove  in  the  ante- 
rior portion  of  the  bone, 
and  had  possibly  opened 
the  capsule  of  the  joint 
at  the  same  time.  The 
Rontgen  ray  clearly 
demonstrated  the  ab- 
sence of  a  complete 
fracture  and  the  exist- 
ence of  a  deep  furrow, 
with  numerous  frag- 
ments on  each  side. 
The  X-ray  apparatus 
also  proved  of  the  great- 
est practical  utility  in 
showing  the  displace- 
ment of  fragments  in 
gunshot  fractures  of  the 
long  bones,  thus  ena- 
bling the  surgeons  to 
resort  to  timely  measures 
to  prevent  vicious  union. 
The  fluoroscope   has 

added  much  to  the  diagnostic  value  of  skiagraphy  in  the  diagnosis 
of  gunshot  wounds  and  other  injuries.  In  the  light  of  recent  ex- 
perience the  X-ray  has  become  an  indispensable  diagnostic  resource 
to  the  military  surgeon  in  active  service,  and  the  suggestion  that 
every  chief  surgeon  of  all  army  corps  be  supplied  with  a  portable 
apparatus  and  an  expert  to  use  it  must  be  considered  a  timely  and 
urgent  one. 

Prognosis. — The  small-caliber  bullet  inflicts  injuries  that,  if 
not  fatal  from  its  immediate  effects,  are  favorable  to  successful  treat- 
ment. This  consists  largely  in  the  prevention  of  wound  infection. 
The  relative  number  of  dead  and  wounded  in  future  wars  is  prob- 
ably well  shown  by  our  experience  in  Cuba.  During  the  whole 
'5 


Fig.   140. — Bullet  in  knee  joint. 


226 


GUNSHOT    WOUNDS. 


campaign  not  more  than  300  men  were  killed,  while  nearly  1400 
.were  wounded.  In  Porto  Rico  the  relative  proportion  of  wounded 
to  dead  was  still  greater.  Unless  some  vital  organ  is  injured  or 
death  occurs  from  acute  hemorrhage,  the  wounded  man  has  a  good 
chance  for  recovery  if  infection  is  prevented  by  the  timely  applica- 
tion of  the  first-aid  dressing.  Wounds  of  the  soft  parts,  outside 
any  of  the  large  cavities  of  the  body,  heal,  as  a  rule,  by  primary 
intention  under  the  first-aid  dressing  in  the  course  of  a  week  or  two. 
As  yet  we  have  received  no  reliable  detailed  accounts  of  the 
experience  of  surgeons  during  the  war  that  is  now  raging  in  South 


Fig.  141. — Bullet  in  the  hand,  between  the  metacarpal  bones  of  the  index-  and  middle 

fingers. 


Africa,  but  from  the  fragmentary  accounts  it  is  evident  that  it  is  but 
a  repetition  of  our  own  experience  during  the  Spanish-American 
war.  A  recent  writer  to  the  Netley  hospital  says:  "Surgeon- 
Captain  Steele,  of  the  Militia  Medical  Staff  Corps,  who  was  orderly 
officer  for  the  day,  took  me  to  Major  Dick,  R.A.M.C.,  in  whose 
charge  most  of  the  surgical  cases  had  been  placed,  and  who  kindly 
took  me  round  some  of  the  wards.  Among  the  cases  were  men  who 
had  been  pierced  by  bullets  in  almost  every  direction.  Thus,  there 
were  cases  in  which  the   head  had  been  wounded,  and  apparently 


PROGNOSIS.  227 

even  the  brain  traversed  ;  others  were  shot  through  the  thorax, 
while  several  had  been  wounded  in  the  abdomen,  groin,  and  buttock, 
and  in  both  upper  and  lower  limbs.  Shoulder-  and  elbow-joint  had  in 
turn  been  pierced.  In  one  or  two  cases,  of  which  I  give  brief  notes, 
the  body  had  been  traversed  literally  from  one  end  to  the  other. 
The  wounds,  with  the  exception  t)f  a  very  few,  had  almost  entirely 
healed,  and  in  a  large  number  of  cases  had  left  no  symptom  what- 
ever behind  them.  Most  interesting  of  those  with  appreciable 
after-effects  were  cases  of  nerve  injury,  in  which  a  degree  of  either 
pain  or  paralysis,  or  both,  remained." 

G.  H.  Makins,  consulting  surgeon  with  the  forces  in  South 
Africa,  writes  as  follows  on  the  clinical  signs  and  course  of  the 
wounds  :  "  The  actual  infliction  of  the  wound  gives  rise  to  little 
pain, — usually  a  sharp,  burning  sensation, — and  is  followed  by  re- 
markably little  shock  ;  severe  shock  is,  in  fact,  uncommon,  even 
when  vital  organs  are  struck.  Omitting  the  cases  in  which  a  large 
vascular  trunk  is  struck  in  a  limb  or  in  the  body,  external  hemor- 
rhage is  slight,  and  even  when  a  large  trunk  is  implicated,  it  more 
often  gives  rise  to  intermediate  or  secondary  hemorrhage  than  to 
severe  primary  bleeding.  In  fact,  such  evidence  as  can  be  obtained 
points  to  but  few  deaths  taking  place  on  the  field  from  primary 
bleeding.  Although,  however,  external  hemorrhage  is  slight,  in- 
terstitial bleeding  into  the  limbs  or  into  the  cavities  of  the  trunk 
during  the  first  few  hours  after  the  injury  is  common,  and  may  be 
severe  or  fatal.  As  will  be  remarked  later,  traumatic  aneurysms  are 
comparatively  frequent.  Again,  the  scoring  or  contusion  of  nerve- 
trunks  gives  rise  to  more  or  less  complete  paralysis  or  to  severe 
neuralgic  pain  during  and  after  the  healing  of  the  wound. 

"The  tendency  to  run  an  aseptic  course  is  very  marked,  and 
deep  suppuration  or  diffuse  cellulitis  is  distinctly  rare.  This  de- 
pends on  the  smallness  of  the  wound,  the  aseptic  nature  of  the 
bullet,  and  the  fact  that  foreign  bodies,  such  as  pieces  of  clothing, 
are  comparatively  rarely  introduced. 

•'  The  asepticity  of  the  bullet  is,  I  think,  clearly  demonstrated,  and 
is  probably  due  to  the  fact  that  the  bullet,  in  traveling  through  the 
barrel  of  the  rifle,  obtains  a  completely  fresh  surface,  and  with  such 
enters  the  body.  As  to  the  frequency  with  which  portions  of  cloth- 
ing are  carried  into  the  wound,  it  should  be  remarked  that  this  varies 
considerably  with  the  nature  of  the  material  traversed.  The  open- 
ing in  the  khaki  jacket,  for  instance,  from  the  hardness  of  the 
material,  is  usually  a  clean  slit  ;  but  if  the  bullet  has  to  traverse  a 
flannel  shirt,  loss  of  substance  and  transference  of  this  to  the 
wound  is  more  common,  while  in  the  case  of  the  Highland  kilt, 
where  .several  layers  of  cloth  have  to  be  traversed,  portions  are 
comparatively  frequently  found  in  the  wounds. 

"  The  slight  tendency  to  suppuration  exhibited  by  the  tracks  is, 
however,  I  think  due  to  some  inherent  character  of  the  tissue, 
probably  explained  by  the  condensation  and  surface  destruction  of 


228  GUNSHOT    WOUNDS. 

the  tissue  resulting  from  the  force  and  velocity  of  the  bullet,  since 
the  tracks  neither  bleed  freely  at  first  nor  do  they  furnish  any 
material  amount  of  serous  discharge  during  the  process  of  healing. 
They  remain,  indeed,  dry  throughout,  and  their  slight  tendency  to 
suppuration  is  well  instanced  by  the  fact  that  if  for  any  reason  a 
deep  part  of  a  track  becomes  infected  and  suppurates,  the  inflamma- 
tory process  shows  no  tendency  to  spread  by  the  original  wound, 
but  comes  to  the  surface  locally. 

"  During  the  process  of  healing  the  apertures,  and  with  them 
the  track,  gradually  contract,  the  aperture  of  entry  is  closed  by  dry 
clot,  and  diminishes  in  size,  the  contused  margin  becoming  a  small 
black  depressed  spot  in  the  center,  while  the  aperture  of  exit  often 
closes  with  an  ordinary  reddened  cicatrix.  When  fully  healed,  the 
ends  of  the  contracted  track  can  be  felt  as  two  small  indurated 
spots,  often  so  hard  as  to  give  the  impression  of  an  included  foreign 
body.  The  extreme  density  of  the  resulting  cicatrix  in  the  deeper 
parts  of  the  wound  is  a  factor  of  much  importance,  since  if  it  in- 
volves tendons  or  nerves,  considerable  impairment  of  movement  or 
signs  of  nerve  pressure  are  produced.  Again,  a  track  through  the 
muscles  of  the  leg,  for  instance,  will  more  or  less  tie  the  whole 
thickness  of  the  traversed  structures  together  from  the  aperture  of 
entry  to  that  of  exit,  both  of  which  may  be  seen  to  be  drawn  in 
as  dimples  when  the  muscles  are  put  in  action.  This  condition 
naturally  gives  rise  to  much  subsequent  stiffness  and  pain  on 
movement,  and  forms  one  of  the  most  troublesome  after-conse- 
quences in  simple  flesh  wounds.  The  scars  left  in  the  situation  of 
the  two  apertures  are  not  more  apparent  than  those  resulting  from 
a  large  acne  pustule. 

"  The  above  description  of  uncomplicated  flesh  wounds  shows 
that  the  treatment  of  these  injuries  is  simple  in  the  extreme.  It 
has  consisted  almost  entirely  in  the  apphcation  of  pads  of  dry 
bicyanid  gauze  and  a  little  wool  after  the  parts  surrounding  the  open- 
ings have  been  washed  with  an  antiseptic  lotion,  either  a  solution 
of  carbolic  acid  or  of  perchlorid  of  mercury.  Fixation,  beyond 
that  resulting  from  the  bandaging  on  of  the  dressing,  has  rarely 
been  needed.  In  the  foregoing  remarks  concerning  the  aseptic 
course  of  the  wounds  considerable  stress  has  been  laid  on  the 
aseptic  character  of  the  bullet  and  the  nature  of  the  injury  to  the 
soft  parts  ;  but  I  should  not  neglect  to  add  that  the  purity  of  the 
atmosphere  and  the  apparently  innocuous  nature  of  the  dust  on  the 
high  veld,  when  the  camp  is  a  fresh  one,  must  also  be  credited  as 
important  factors  in  the  happy  results  which  have  been  attained  up 
to  the  present.  It  will  be  noted  that  no  remark  has  been  made  as 
to  the  treatment  of  retained  bullets,  and  this  for  two  reason  :  first, 
retained  Mauser  bullets  are  uncommon  ;  and,  secondly,  if  not  caus- 
ing trouble,  they  are  best  left  alone,  unless  they  lie  in  very  superficial 
positions." 

Traumatic  aneurysm  will  be  more  frequently  observed  in  the 


TREATMENT. 


229 


future  than  in  the  past,  as  the  new  bullet  inflicts  vessel  wounds  that 
bleed  more  profusely  than  similar  wounds  made  by  the  large-caliber 
leaden  bullet,  and  are  less  favorably  adapted  for  the  spontaneous  ar- 
rest of  hemorrhage  by  thrombus  formation.  Penetrating  o-unshot 
wounds  of  the  skull,  if  the  patient  survives  the  immediate  effects  of 
the  injury,  are  grave  injuries,  but  not  necessarily  fatal,  as  a  fair  per- 
centage of  recoveries  will  reward  early  surgical  intervention  under 
strict  aseptic  precaution.  Penetrating  wounds  of  the  chest,  if  the 
heart  and  large  blood-vessels  escape  injury,  usually  heal  by  primary 
intention  under  the  first  dressing.  Gunshot  wounds  of  the  abdomen 
at  and  above  the  level  of  the  umbilicus  less  frequently  demand 
operative  interference  and  result  in  fewer  deaths  than  similar 
wounds  in  the  area  of  the  small  intestine.  Comminuted  gunshot 
fractures  and  penetrating  wounds  of  any  of  the  large  joints  not 
complicated  by  injury  of  large  vessels  and  nerves  are  now  within 
the  range  of  successful  conservative  surgery. 

The  prognosis  of  any  gunshot  wound  is  more  favorable  in  cases 
in  which  no  probing  has  been  done  and  in  which  the  first-aid  dressing 
was  applied  immediately  or  soon  after  the  injury  was  received.  Even 
in  cases  in  which  infection  takes  place  the  prognosis  is  much  more 
favorable  to-day  than  it  was  before  antiseptic  surgery  was  prac- 
tised, as  we  are  now  in  possession  of  ways  and  means  that  will 
enable  us  to  ward  off  death  from  septicopyemia.  This  is  accom- 
plished by  establishing  free  drainage  and  by  resorting  to  antiseptic 
irrigation  at  short  intervals  or  continuously,  procedures  also  relied 
upon  in  limiting  the  indications  for  the  performance  of  secondary 
mutilating  operations. 

Treatment. — The  surgeon  in  daily  practice  has  learned  long 
ago  that  every  accidental  wound  must  be  regarded  and  treated 
practically  as  an  infected  wound.  In  this  respect  the  military  sur- 
geon of  to-day  has  the  advantage  over  his  colleague  in  civil  life, 
in  knowing  that  the  small-caliber  bullet  inflicts  wounds  that  per  se 
are  more  often  a.septic  than  septic,  and  these  are  the  wounds  he  is 
most  frequently  called  upon  to  treat.  Our  recent  observations  in 
Cuba  and  Porto  Rico  have  shown  that  the  small-caliber  jacketed 
bullet  seldom  carries  with  it  into  the  wound  clothing  or  any  other 
infectious  substances.  Most  of  the  wounds  of  the  soft  tissues  un- 
complicated by  visceral  injuries,  which  in  themselves  would  become 
a  source  of  danger,  healed  by  primary  intention  in  a  remarkably 
short  time.  If  infection  followed,  it  usually  did  so  in  the  super- 
ficial portion  of  the  wound  in  connection  with  the  skin,  and,  what 
is  more  than  suggestive,  the  wound  of  exit  was  more  frequently 
infected  than  the  wound  of  entrance.  This  can  be  satisfactorily 
explained  by  the  larger  size  of  the  wound  and  the  more  extensive 
laceration  and  tearing  of  the  tissues.  In  many  of  the  cases  ideal 
healing  of  the  wound  did  not  occur,  owing  to  a  subsequent  limited 
superficial  suppuration  of  the  wound.  The  deep  tissues  were  .seldom 
implicated   in  such  cases.      I  have   reason  to  believe  that  some  of 


230  GUNSHOT    WOUNDS. 

the  gunshot  fractures  that  suppurated  had  such  a  source  of  infec- 
tion— that  is,  the  extension  of  a  superficial  infection  to  the  seat  of 
fracture. 

The  failures  in  protecting  the  more  serious  wounds  against 
infection  are  attributable  principally  to  three  causes  :  (i)  Inade- 
quate supply  of  first-dressing  material  at  all  times  and  in  all  places. 
(2)  Faulty  application  of  first  dressing,  (3)  Unnecessary  change 
of  first  dressing. 

The  medical  officers  with  the  regiments  and  in  the  field-hos- 
pitals were  hampered  in  their  work  by  an  insufficiency  of  proper 
dressing  material.  This  was  due  to  the  haste  in  which  the  cam- 
paign was  planned  and  finished,  the  difficulties  encountered  in 
transporting  the  hospital  supplies  to  the  front,  and  the  unexpected 
large  number  of  wounded.  These  reasons  sufficiently  explain  the 
unavoidable  lack  of  dressing  material  when  and  where  it  was  most 
needed.  The  first-aid  packages  were  more  frequently  found  in  the 
field-hospitals  than  on  the  person  of  the  soldier.  Many  of  the 
dressings  were  too  small  and  too  insufficiently  secured  to  keep 
them  in  place  in  transporting  the  wounded  from  the  front  to  the 
field-hospitals.  As  a  rule,  not  enough  attention  was  paid  to  the 
immobilization  of  the  injured  part,  an  important  element  in  securing 
rest  for  the  wound  and  in  guarding  against  displacement  of  the 
dressings.  It  is  a  source  of  regret  that  plaster-of-Paris  dressings 
were  not  more  frequently  employed  in  the  treatment  of  gunshot 
fractures,  over  the  primary  dressing,  before  transporting  the  patients 
to  the  rear. 

Another  very  obvious  cause  of  infection  was  the  too  common 
practice  of  unnecessary  change  of  dressing.  The  transfer  of 
patients  from  one  surgeon  to  another  could  not  be  avoided. 
Patients  brought  from  the  firing-line  or  first  dressing  station  to  the 
field-hospital  were  usually  subjected  to  a  change  of  dressing,  and 
when,  a  few  days  later,  they  reached  the  General  Hospital  at 
Siboney,  they  had  to  undergo  the  same  ordeal  and  often  not  only 
once,  but  as  many  times  as  they  came  into  the  hands  of  another 
surgeon.  Patients  not  thus  treated  were  dissatisfied,  as  the  laymen 
are  still  laboring  under  the  erroneous  impression  that  the  oftener  a 
wound  is  dressed,  the  sooner  it  will  heal.  It  is  difficult  to  eradicate 
so  deeply  rooted  and  time-honored  a  belief,  and  patients  will  con- 
tinue to  clamor  for  a  change  of  dressing,  the  good-natured,  hard- 
working surgeons  only  too  often  complying  with  such  unreasonable 
requests. 

The  evil  of  meddlesome  surgery  became  very  apparent  during 
the  brief  Cuban  campaign,  and  it  has  taught  us  an  important  lesson 
that  must  be  heeded  in  the  future.  Our  military  surgeons  must 
learn  to  realize  more  than  ever  the  value  and  importance  of  the 
first-aid  dressing  in  the  prevention  of  wound  infection.  In  all  cases 
in  which  the  first  examination  does  not  reveal  the  existence  of 
complications    that    require    subsequent    operative    treatment,    the 


FIRST-AID    PACKAGE    IN    MILITARY    SURGERY.  23 1 

diagnosis  tag  should  convey  this  important  instruction  :  "  Dress- 
ings not  to  be  tOHcJud  unless  syinptojns  demand  it."  Such  instruc- 
tion is  significant,  and  must  be  followed  to  the  letter  by  all  sur- 
geons in  subsequent  charge  of  the  patient.  After  the  first  dressing 
has  been  applied,  it  should  not  be  removed  except  for  good  and 
substantial  reasons.  ]\Iuch  can  be  done  in  the  after-treatment  in 
the  way  of  readjusting  the  bandage  and  in  immobilizing  the  injured 
part,  but  the  first  dressing  must  remain  unless  local  or  general 
symptoms  set  in  that  would  warrant  its  removal.  Malaria  and 
yellow  fever,  which  crept  in  upon  us  in  Cuba  so  insidiously,  were 
responsible  for  many  unnecessary  changes  of  dressing.  The  ap- 
pearance of  fever  in  a  wounded  man  naturally  leads  to  the  suspicion 
that  there  is  something  WTong  with  the  wound.  Many  dressings 
were  changed  on  this  ground,  but  nothing  abnormal  was  found  in 
the  wounds.  A  day  or  two  later,  however,  the  nature  of  the  fever 
was  recognized,  and  the  patients  were  either  given  quinin  or  were 
sent  to  the  yellow  fever  hospital,  according  to  the  diagnosis  made. 
Every  change  in  dressing,  more  especially  in  military  practice,  is 
attended  by  risk  of  infection  and  must  be  scrupulously  avoided,  unless 
local  or  general  symptoms  indicate  the  exist oice  of  complications  that 
demand  surgical  intervention. 

In  detailing  this  it  is  not  my  purpose  to  cast  any  reflections  on 
the  work  of  our  surgeons  ;  on  the  contrary,  I  willingly  bear  testi- 
mony to  the  ability,  faithfulness,  and  unselfishness  with  which  they 
discharged  their  trying,  onerous  duties.  A  better  and  more  con- 
scientious group  of  medical  officers  it  would  be  difficult  to  select 
anywhere.  The  results,  on  the  whole,  were  excellent,  but  I  am 
certain  that  they  can  be  improved  upon  in  the  future  by  la}ing 
more  stress  on,  and  giving  more  attention  to,  the  value  and  impor- 
tance of  the  first-aid  dressing.  I  wish  to  repeat,  and  in  a  most 
forcible  way,  the  language  of  the  late  Professor  von  Nussbaum  : 

"  Tlie  fate  of  the  woimded  rests  in  the  hands  of  the  one  ivho 
applies  the  first  dressing. ' ' 

FIRST-AID  PACKAGE  IN  MILITARY  SURGERY. 

It  is  fortunate  for  the  armed  forces  of  the  world,  but  unfortu- 
nate for  military  surgery,  that  no  great  wars  have  occurred  since 
antiseptic  and  aseptic  surgery  came  into  general  use.  During  the 
time  the  Franco-Prus.sian  war  was  fought,  the  last  great  war  since 
our  own  great  civil  conflict,  Lister  was  quietly  at  work  framing  the 
great  principles  that  have  recast  the  work  of  the  surgeon.  Anti- 
septic and  a.septic  surgery  has  not  as  yet  had  an  extensive  and  a 
fair  trial  on  the  battle-field.  Carbolic  acid  solutions  were  employed 
to  some  extent  by  the  German  surgeons  during  the  I'ranco-I'russian 
war,  but  liillroth's  extensive  observations  in  a  number  of  large 
military  hospitals  led  him  to  believe  that  they  ditl  not  exert  any 
special  influence  in  the  prevention  of  wound  comj^Hcations.  As 
late  as  1861,  .Strohmcjxr,  in   his  classic  work  on  military  surgery, 


232  GUNSHOT    WOUNDS. 

advised  the  use  of  a  wet  compress  in  the  treatment  of  wounds  on 
the  battle-field,  a  method  of  treatment  that  had  been  in  use  from 
time  to  time  since  military  surgery  was  practised.  The  only 
innovation  was  a  gutta-percha  tissue  cover  over  the  compress, 
which  was  used  for  the  purpose  of  retaining  moisture  until  the 
patient  could  reach  the  field-hospital,  where  the  compress  could  be 
changed  as  often  as  was  deemed  necessaiy.  This  treatment  was  a 
decided  improvement  over  some  of  the  old  methods,  such  as  the 
common  practice  of  stuffing  the  wounds  with  infected  charpie  and 
the  barbaric  use  of  boiling  oil,  but  it  was  a  step  backward,  judging 
from  the  present  standpoint  of  wound  infection,  from  the  treatment 
of  wounds  by  the  local  use  of  turpentine,  which  at  one  time  was 
sanctioned  and  extensively  practised  by  German  military  surgeons. 
The  moist  septic  compress  had  a  trial  on  the  most  extensive  scale 
during  the  Civil  War,  and  we  are  familiar  with  the  results.  The 
terrible  experience  with  gunshot  wounds  by  all  the  old  methods  of 
treatment  turned  the  attention  of  military  surgeons  to  the  modern 
treatment  of  wounds  as  soon  as  it  became  well  established  in  civil 
practice.  The  surgeons  in  civil  life  built  the  bridge  across  the 
river  that  separated  the  old  from  the  new  methods  of  wound  treat- 
ment, and  the  military  surgeons  willingly  followed  the  advance 
columns  crossing  it,  eager  and  anxious  to  extend  the  benefits  of 
the  new  discovery  to  the  wounded  soldier. 

The  wars  among  civilized  nations  have  been  too  few  and  on  too 
small  a  scale  to  perfect  the  technic  of  aseptic  surgery  on  the  battle- 
field ;  a  sufficient  experience  has,  however,  accumulated  to  warrant 
the  statement  that  asepsis  will  eventually  bring  about  as  great 
changes  in  military  surgery  as  it  has  already  accomplished  in  civil 
practice.  The  first  tentative  efforts  at  practising  asepsis  in  military 
surgery  were  made  during  the  Russo-Turkish  war.  Reyher  and 
von  Bergmann,  who  took  a  conspicuous  part  in  that  campaign, 
promptly  made  known  the  results  of  their  observations,  and  their 
writings  laid  the  foundation  for  the  modern  treatment  of  gunshot 
wounds.  Two  things  were  brought  out  clearly  during  that  war — 
viz.  (i)  the  value  of  a  first-aid  antiseptic  occlusive  dressing  in  the 
prevention  of  wound  infection,  and  (2)  the  importance  of  immedi- 
ate immobilization  of  gunshot  fractures. 

It  was  during  that  war,  too,  that  the  too  common  practice  of 
searching  for  and  extracting  bullets  on  the  battle-field  and  in  the 
hospitals  was  violently  opposed,  and  strongly  condemned  by  both 
Reyher  and  von  Bergmann.  The  value  of  antiseptic  and  aseptic 
precautions  in  military  practice  has  been  demonstrated  since  that 
time  on  a  limited  scale  in  Bulgaria,  Servia,  Chili,  Greece,  Turkey, 
Japan,  and  at  dififerent  points  in  Africa  in  small  engagements 
between  the  British,  Italian,  and  French  troops  and  the  natives, 
and  lastly  during  the  recent  Spanish-American  war.  It  is  evident 
that  aseptic  military  surgery  will  never  equal  in  its  results  aseptic 
civil  surgery,  owing  to  circumstances  over  which  contending  armies 


FIRST-AID    PACKAGE    IN    MILITARY    SURGERY.  233 

and  governments  have  no  control.  Military  surgery  is  and  always 
will  be  emergency  surger}^  The  difficulty  in  obtaining  and  trans- 
porting the  necessary  medical  supplies  and,  in  large  engagements, 
the  number  of  wounded,  render  it  impossible  to  follow  out  the 
aseptic  precautions  with  the  same  pedantic  care  as  in  private  and 
hospital  practice.  Absolute  asepsis  in  military  surgery  on  the  field 
is  out  of  question,  for  reasons  that  are  apparent  to  any  one  who 
has  taken  part  in  an  active  campaign.  The  limited  experience  of 
the  past  has,  however,  shown  that  the  imperfect  aseptic  precautions 
that  are  applicable  in  the  field  have  done  much  to  minimize  the 
horrors  of  war.  The  modern  small-caliber  bullet  inflicts  wounds 
that  are  particularly  well  adapted  to  successful  treatment  by  a 
primary  antiseptic  occlusive  dressing.  All  civilized  nations  have 
taken  advantage  of  the  modern  treatment  of  wounds  in  their  efforts 
to  extend  its  benefits  to  military  surgery.  Suggestions  from  dif- 
ferent sources  in  this  direction  came  soon  after  antiseptic  surgery 
became  a  generally  recognized  procedure.  It  is  interesting  to 
know  what  has  been  done  in  the  way  of  recommendations  for  asep- 
sis on  the  battle-field.  Antiseptic  powders,  sterile  and  medicated 
cotton,  gauze,  wood-w^ool,  and  other  hygroscopic  substances  have 
been  proposed.  As  antiseptics  iodoform,  salicylic  acid,  carbolic 
acid,  bichlorid  of  mercury,  chlorid  of  zinc,  and  salol  have  been 
most  frequently  mentioned  and  used. 

The  many  difficulties  that  are  met  in  war  in  the  transportation 
of  medical  supplies  make  it  necessary  to  restrict  the  requirements  for 
procuring  and  maintaining  asepsis  to  so  much  as  is  compatible  with 
the  immediate  demands  of  the  principles  upon  which  it  is  based  ; 
that  is,  asepsis  on  the  battle-field  must  be  attempted  by  the  employ- 
ment of  the  most  efficient  and  the  simplest  precautions.  The  value 
of  the  first-aid  dressing,  applied  behind  the  fighting-line  by  the 
wounded  himself,  by  his  comrades,  or  by  members  of  the  hospital 
corps,  is  as  yet  not  generally  admitted.  Legouest,  Delorme, 
Nimier, — French  military  surgeons, — do  not  favor  the  first-aid 
package.  Chauvel  does  not  share  their  view,  and  makes  a  strong 
plea  for  its  general  introduction  into  military  practice.  But  until  1 889 
no  such  packages  were  in  use  in  the  French  army.  Patin  suggested 
the  following  first-aid  package  :  One  elastic  bandage,  one  antiseptic 
gauze  bandage,  two  graduated  compresses  of  the  same  material — 
inclosed  first  in  paraffin  paper,  and,  as  a  cover,  strong  paper  made 
waterproof  by  Iin.seed  oil  and  a  siccative.  Bedoin  proposed,  as  a 
dressing  material  for  the  first  aid,  filtering  paper  sterilized  by  dry 
heat  and  immersion  in  a  I  :  1000  bichlorid  solution  to  which  a  little 
glycerin  is  added,  when  the  paper  is  slowly  dried.  Six  to  eight 
layers  are  applied  over  the  wound,  besides  cotton,  and  the  dressing 
is  held  in  place  by  a  bandage.  The  package  that  he  recomm.ends 
for  .service  in  the  field  contains  six  sheets  of  aseptic  filtering  paper 
40  cm.  sfjuare,  properly  folded,  a  jiiece  of  gutta-percha  tissue  45 
cm.  square,  in  which  the  paper  is  wrapped,  a  thin  rubber  bandage, 


234  GUNSHOT    WOUNDS. 

from  one  to  one  and  a  half  meters  in  length,  and  several  safety-pins. 
The  package  weighs  40  gm. 

Forgue  recommends  iodoform  and  cotton  as  an  occlusive  first- 
aid  dressing. 

The  first-aid  package  of  the  French  army  in  use  at  the  present 
time  is  quadrangular  in  shape,  the  gray  cloth  wrapper  bearing  on 
one  side  printed  directions  for  use.  It  is  opened  by  extracting  the 
thread  used  in  sewing  the  wrapper.  It  contains  an  impermeable 
fabric,  a  small  cushion  of  sublimated  jute,  a  sublimated  gauze  com- 
press, a  bandage,  and  two  safety-pins. 

Mosetig  von  Moorhof  advises  dusting  the  wound  with  iodoform, 
over  which  a  gauze  compress  is  applied,  then  mackintosh  or  some 
other  impermeable  material,  which  is  made  to  overlap  the  gauze  for 
at  least  an  inch,  and  over  this  a  large  hygroscopic  dressing  and 
bandage. 

Wein  recommends  iodoform  gauze  between  two  layers  of 
hygroscopic  cotton  wrapped  in  gutta-percha  tissue  in  a  compact 
package.  Before  applying  the  dressing  it  is  to  be  immersed  in  a 
strong  solution  of  bichlorid  of  mercury  or  a  carbolized  solution,  to 
insure  absolute  asepticity,  when  the  iodoform  gauze  is  applied  next 
to  the  wound,  and  over  it  the  cotton,  gutta-percha,  and,  lastly,  the 
retaining  bandage.  Langenbuch  strongly  advocated  the  closure 
and  sealing  of  the  wounds  by  suturing  and  adhesive  plaster,  a  part 
of  the  field  service  that  he  wished  to  assign  to  the  litter  bearers. 
Liihe  beheved  that  this  method  of  dealing  with  gunshot  wounds 
would  prove  more  effective  if  the  wound  were  first  dusted  with 
iodoform  or  salicylic  acid. 

Port  has  modified  the  recommendations  of  Langenbuch  in  so 
far  that  he  applies  the  adhesive  plaster  in  the  form  of  a  Maltese 
cross,  with  a  central  opening  the  size  of  the  bullet  wound,  which, 
when  the  plaster  is  in  place,  is  covered  with  iodoform  gauze  and 
cotton,  for  the  purpose  of  guarding  against  the  retention  of  wound 
secretions.  The  margins  of  the  gauze  dressing  are  fastened  to  the 
surface  with  a  rubber  solution,  and  the  whole  is  retained  by  strips 
of  adhesive  plaster.  In  1869  von  Esmarch  devised  the  triangular 
bandage,  with  printed  illustrations  for  its  use.  During  the  early 
history  of  antiseptic  surgery  he  recommended  balls  of  chlorid  of 
zinc,  jute,  and,  later,  wipers  of  sublimated  sawdust  in  gauze  bags 
for  the  field  service.  His  typical  first-aid  package  was  a  later  prod- 
uct of  his  fertile  brain.  It  consists  of  his  bandage,  two  compresses 
of  sublimated  gauze  10  cm.  broad  and  lOO  cm.  long,  each  wrapped  in 
waxed  paper,  and  an  antiseptic  cambric  bandage  10  cm.  broad  and 
2  meters  long.  The  whole  package,  in  rubber  cloth,  weighs  100 
gm.  According  to  Seydl,  the  first-aid  package  of  the  German 
army  in  1893  contained  a  sublimate  gauze  bandage  five  meters  in 
length,  two  compresses  of  the  same  material,  and  one  safety-pin, 
the  whole  wrapped  in  a  compact  form  in  waterproof  linen  cloth 
that  is  sewed  into  the  shirt  of  the  uniform  of  officers  and  men. 


FIRST-AID    PACKAGE    IN    MILITARY    SURGERY.  235 

In  1855  an  order  was  issued  in  England  from  the  Medical 
Department,  which  required  that  a  field  dressing  should  form  a 
component  part  of  every  British  soldier's  kit  in  active  service,  so 
as  to  be  available  at  all  times  and  in  all  places  as  a  first  dressing 
for  wounds.  The  materials  and  form  of  the  first  field  dressing 
were  ordered  to  be  as  follows  :  Bandage  of  fine  calico  4  yards  long 
and  3  inches  wide  ;  fine  lint  12  inches  long  and  3  inches  wide, 
folded  flat  and  fastened  by  four  pins.  It  was  ordered  to  be  carried 
in  the  soldier's  knapsack.  During  the  Ashanti  war,  1873-74,  the 
dressing  included  a  packet  of  lint  on  which  a  little  simple  ointment 
had  been  spread,  inclosed  in  waxed  paper,  a  triangular  bandage, 
two  safety-pins,  and  a  small  packet  of  ordinary  pins.  These  arti- 
cles were  folded  into  a  small  flat  package  4  inches  by  3  i^  inches 
by  I  inch,  which  was  covered  by  waxed  paper.  It  was  carried  in 
a  breast  pocket,  in  the  lining  of  the  left  side  of  the  tunic,  the 
pocket  being  made  of  a  suitable  size.  Later,  this  package  was 
ordered  to  be  carried  in  a  sewn-up  pocket  on  the  inside  of  the  skirt 
of  the  soldier's  jacket.  Since  1891  the  package  is  made  upas 
follows  :  Within  an  outer  gray,  fine  linen  cover  is  a  thin  waterproof 
cambric  inside  cover  that  is  rendered  air-tight  by  being  cemented 
at  the  edges.  Both  covers  can  be  readily  opened  when  necessary. 
The  inner  cover  contains  two  safety-pins,  a  piece  of  waterproof 
cambric  1 2  inches  by  6  inches,  and  this  incloses  a  gauze  bandage 
4^  yards  long,  folded  flat  into  a  package  4  inches  by  2^  inches  ; 
a  piece  of  gauze  17  inches  by  13  inches,  also  folded  flat  ;  about 
160  grains  of  compressed  flax  charpie  between  layers  of  gauze. 
All  the  dressing  materials  are  rendered  antiseptic  by  impregnation 
with  bichlorid  of  mercury  i  :  looo.  The  weight  of  the  complete 
dressing  is  2  ounces. 

Metallic  cases  have  been  recommended  by  Majewski,  Port,  and 
others  for  the  safe-keeping  of  the  dressing  materials.  Port  sug- 
gested a  piece  of  tin  that,  when  folded,  would  be  about  the  size  of 
an  ordinary  envelop,  and  that  was  to  be  sewed  into  the  uniform 
over  the  region  of  the  heart,  for  the  double  purpose  of  protecting 
this  important  organ  against  bullets  and  at  the  same  time  serving 
as  a  case  for  the  dressing  material. 

During  the  Spanish-American  war  the  Surgeon-General  issued 
272,000  first-aid  packages  to  the  troops  in  Cuba  and  Porto  Rico 
and  the  soldiers  in  the  home  camps.  Two  kinds  of  packages  were 
used.  The  one  in  a  pale-red  cover  contained  two  antiseptic  com- 
presses of  sublimated  gauze  in  oiled  paper,  one  antiseptic  sublimated 
cambric  bandage  with  safety-pin,  one  triangular  Ivsmarch  bandage 
with  .safety-pin.  Directions  printed  on  package  :  "  Place  one  of  the 
compre.s.scs  on  the  wound,  removing  the  oiled  paper.  In  cases  of 
large  wounds  open  the  compress  and  cover  the  whole  wound. 
Apply  the  anti.septic  bandage  over  the  compress.  Then  use  the 
triangular  bandage  as  shown  by  illustrations  on  the  .same."  The 
other  package  in  a  yellow  cover  contained  the  same  materials  and 


236  GUNSHOT    WOUNDS. 

directions,  but  was  different  in  shape,  somewhat  larger,  narrower, 
and  thicker. 

All  the  first-aid  packages  that  have  been  described,  including 
those  furnished  our  own  army,  are  too  bulky  for  first-aid  dressing 
in  the  field.  The  packages  used  during  the  Spanish- American  war 
did  excellent  service  in  the  field-hospitals,  but  there  is  no  place  in 
the  uniform  of  the  soldier  where  they  would  be  tolerated  for  any 
length  of  time  for  the  purpose  for  which  they  are  intended.  Long- 
more  made  the  statement  that  during  the  Egyptian  campaign  the 
first-aid  packages  issued  to  the  troops  were  used  for  almost  every- 
thing else  except  as  a  dressing  for  wounds. 

During  my  service  in  Camp  Tanner  I  supplied  the  Illinois  troops 
with  a  small  first-aid  package,  and  every  soldier  left  the  State  with 
one  of  these  packages  sewed  into  the  skirt  of  the  uniform  on  the 
left  side.  These  packages  remained  in  place  and  were  often  made 
use  of  in  the  treatment  of  accidental  wounds.  No  definite  con- 
clusions have  been  reached  as  to  the  best  place  for  these  packages 
on  the  person  of  the  soldier.  The  helmet,  the  knapsack,  the  cart- 
ridge box,  a  hollow  space  in  the  butt  of  the  gun,  the  uniform  at  a 
place  over  the  heart,  and  the  skirt  have  all  been  recommended  as 
the  most  convenient  places  for  carrying  the  packages  during  an 
active  campaign.  As  the  officers  and  noncombatants  do  not  carry 
a  gun,  some  place  in  the  uniform  or  the  accoutrement  must  be 
found  where  such  a  package  can  be  carried  without  inconvenience 
and  without  coming  in  conflict  with  military  regulations.  It  must 
be  stored  in  some  part  of  the  soldier's  outfit  that  he  is  not  likely  to 
throw  away  during  a  forced  march  or  in  the  heat  of  battle.  The 
cartridge  or  sword  belt  is  about  the  last  thing  a  soldier  will  part 
with,  and  it  is  for  this  reason  that  a  number  of  years  ago  I  made 
the  suggestion  to  sew  the  first-aid  package  in  the  middle  and  upon 
the  inner  side  of  the  belt.  As  the  modern  cartridge  belt  is  made 
of  canvas  cloth,  no  difficulty  presents  itself  in  fastening  the  package 
by  stitching  it  to  its  inner  surface.  Oiled  linen  cloth  or  thin  leather 
would  recommend  themselves  for  the  outer  wrapper.  To  be  worn 
in  this  locality  without  objection  on  the  part  of  the  soldier  or  the 
military  authorities  the  package  must  be  small.  Large  packages 
of  any  kind  will  never  prove  satisfactory.  The  first-aid  package 
for  use  in  the  field  must  meet  the  following  requirements  : 

1.  The  material  it  contains  for  the  dressing  of  the  wound  must 
not  only  be  aseptic,  but  antiseptic. 

2.  The  antiseptic  used  must  be  nonvolatile  and  resistant  to 
chemic  changes  for  a  long  time. 

3.  It  must  contain  a  fixation  material  that  will  prevent  displace- 
ment of  the  dressing  after  it  has  been  applied. 

4.  Its  size  must  be  such  as  not  to  inconvenience  the  soldier  or 
to  prove  a  source  of  objection  to  the  military  authorities. 

5.  The  dressing  employed  should  not  interfere  with  the  free 
evaporation  of  the  wound  secretion. 


FIRST-AID    PACKAGE    IN    MILITARY    SURGERY.  237 

As  the  quantity  of  dressing  material  must  necessarily  be 
limited  in  the  dressing  of  gunshot  wounds  behind  the  fighting-line, 
it  is  evident  that  better  results  will  be  obtained  if  it  is  impregnated 
with  an  antiseptic  substance  than  if  it  is  composed  simply  of  sterile 
material.  Perfect  asepsis  on  the  battle-field  is  a  happy  dream  that 
will  probably  never  be  realized.  Disinfection  of  the  wound  and  its 
immediate  vicinity  before  the  application  of  the  dressing  under  such 
circumstances  is  absolutely  out  of  question.  Bullet  wounds  should 
never  be  touched,  much  less  explored,  before  the  first-aid  dressing 
is  applied. 

The  necessity  for  the  use  of  antiseptic  dressings  in  the  treat- 
ment of  recent  gunshot  wounds  has  been  shown  most  conclu- 
sively by  the  ingenious  experiments  of  Bogdan.  This  investigator 
showed,  by  bacteriologic  experiments,  that  the  skin  of  soldiers 
protected  by  the  regulation  clothing,  when  in  active  service,  con- 
tains, on  an  average,  to  every  five  cubic  centimeters  4429  patho- 
genic microbes,  and  he  found,  by  further  investigation,  that  in  gun- 
shot wounds  treated  by  sterile  dressing  material  the  microbes 
increased  much  more  rapidly  than  under  sublimated  gauze.  He 
studied  the  results  of  twenty -two  dressings  after  twenty -four  hours, 
and  found  that  under  the  sterile  dressing  the  microbes  had  in- 
creased to  780,729,  and  under  the  sublimated  gauze  to  19,668,  the 
relative  proportion  of  increase  being  4 :  1 76  or  i  :  44.  These  ex- 
periments only  prove,  what  we  would  naturally  expect,  that  the 
increase  of  microbes  is  diminished  by  the  employment  of  antiseptic 
dressings  in  the  treatment  of  wounds  that  can  never  be  regarded  as 
aseptic. 

Carbolic  acid  is  volatile,  and  is  not  adapted  for  dressings  in  the 
field.  Corrosive  sublimate,  the  most  important  antiseptic  employed 
at  the  present  time,  is  a  very  fickle  chemic  substance,  prone  to  de- 
composition by  chemic  changes  that  destroy  its  antiseptic  properties 
when  incorporated  in  dry  dressing  material.  Iodoform  has  no  de- 
cided antiseptic  properties,  and  can  not  be  relied  upon  in  the  protec- 
tion of  recent  wounds  again.st  infection.  Salicylic  acid  has  often  been 
proposed  from  different  sources  as  the  most  valuable  antisejitic  for 
the  first-aid  dressing.  Boric  acid  is  another  stable  and  valuable 
antiseptic,  but  it  can  not  be  relied  upon  exclusively  as  an  an- 
tiseptic in  a  small  dressing  in  preventing  wound  infection.  For 
years  I  have  relied  on  a  combination  of  these  two  antiseptics  as  a 
drying  antiseptic  powder  as  an  aid  in  the  treatment  of  recent  wounds. 
The  formula  used  is  boric  acid  four  parts,  salicylic  acid  one  part. 
The  line  of  suturing  is  covered  with  a  layer  of  the  borosalicylic 
powder,  deep  enough  to  bury  the  sutures  out  of  sight  before  the 
hygroscopic  sterile  dressing  is  applied.  The  primary  wound  secre- 
tion disscjlves  a  part  of  the  powder  applied,  and  the  resulting  anti- 
.scptic  fluid  resembles  in  its  effects  very  closely  Thiersch's  solution, 
which  has,  for  good  reasons,  become  very  popular  as  a  safe,  non- 
irritating,  and  yet  efficient  antiseptic.     Several  years  ago  I  recom- 


238 


GUNSHOT    WOUNDS. 


mended  the  borosalicylic  powder  in  the  foregoing  proportion  as  a 
valuable  component  part  of  the  first-aid  package,  and  an  extensive 
experience  has  strengthened  my  faith  in  its  antiseptic  properties. 

Fixation  of  the  dressing  by  the  triangular  or  roller  bandage 
can  not  be  relied  upon  in  preventing  displacement  of  the  dressing 
during  the  transportation  of  the  patient  from  the  field  to  the  hos- 
pital. The  dressing  must  be  held  in  place  by  one  or  two  strips  of 
rubber  adhesive  plaster,  which  must  constitute  an  essential  com- 
ponent part  of  all  future  first-aid  packages.  The  size  of  the  pack- 
age must  be  reduced  to  a  minimum,  to  do  away  with  the  most 
serious  objections  against  its  employment  in  field  service,  and  this 
can  be  done  by  selecting  only  such  materials  as  are  essential  in  a 
primary  dressing  for  small  wounds.  All  primary  dressings  for 
recent  gunshot  wounds  should  be  dry,  and  nothing  must  be  placed 
in  the  way  of  free  evaporation  of  the  wound  secretion  ;  hence  all 
impermeable  covers  outside  of  the  hygroscopic  dressing  must  be 
abandoned.  A  dry  dressing  is  one  of  .the  very  best  means  of  pre- 
venting  wound   infection,  and   nothing   should   interfere   with   the 


Fig.  142. — Cartridge  belt  with  first-aid  package  sewed  on  inner  surface. 


conversion  of  the  wound  secretion  and  dressing  employed  in  secur- 
ing a  dry  crust,  which  hermetically  seals  the  wound.  Sterile  ab- 
sorbent cotton  is  far  superior  to  gauze  as  a  primary  dressing  for 
bullet  wounds,  as  its  hygroscopic  capacity  is  much  greater,  at  the 
same  time  furnishing  a  more  efficient  filter  for  the  exclusion  of 
microbes  from  the  wound  from  without.  I  would  suggest  the 
following  first-aid  package  for  field  use  and  emergency  work  : 

A  soft,  flexible  package,  about  i  ^  cm.  in  thickness,  6 1^  cm.  in 
width,  and  19  cm.  in  length.  It  consists  of  two  drams  of  borosali- 
cylic powder  (4  :  i)  in  an  aseptic  fibrous  paper  envelop  ;  two  pieces 
of  compressed  cotton,  each  2  ]^  by  4  inches  ;  one  piece  of  absor- 
bent gauze,  triangular  in  shape,  being  one-half  of  a  square  yard  ; 
two  safety-pins  attached  to  the  gauze  ;  two  strips  of  rubber  adhesive 
plaster,  each  i  inch  in  width  and  8  inches  in  length.  The  whole, 
after  being  compressed  under  heavy  pressure,  is  incased,  with  asep- 
tic precautions,  in  a  cover  of  thin  mackintosh  cloth  and  sealed  with 
rubber  cement.  For  military  service  the  latter  is  included  in  a 
waterproof  duck  casing  of  sufficient  width  to  allow  the  lateral  mar- 
gins to  be  stitched  to  the  inner  surface  of  the  cartridge  belt.      The 


FIRST-AID    PACKAGE    IX    MILITARY    SURGERY.  239 

weight  of  the  package,  including  the  duck  cover,  is  710  grains; 
\vithout  the  latter,  540  grains. 

In  using  the  package  the  powder  is  applied  to  the  wound,  when 
the  lintin  is  used  as  a  compress,  held  in  place  by  the  strips  of  adhe- 
sive plaster  and  the  gauze  bandage  over  it.  If  two  wounds  are  to 
be  dressed  at  the  same  time,  as  is  usually  the  case  in  modern  war- 
fare, the  contents  of  the  package  are  equally  divided  and  used, 
which  can  be  done  without  materiall}'  impairing  the  efficiency  of 
the  dressing.  The  slight  hemorrhage  in  wounds  inflicted  by  the 
small-caliber  bullet  will  soon  saturate  a  part  of  the  dressing,  which, 
by  evaporation,  will  soon  convert  the  antiseptic  powder  and  the 
cotton  into  a  dry  antiseptic  crust,  the  very  best  protection  for  the 
wound  against  infection. 

The  important  question  arises  :  Where  and  by  whom  should 
the  first-aid  dressing  be  applied?  A  number  of  prominent  military 
surgeons  of  the  present  time,  among  them  Longmore,  W.  Roth, 
Wein,  and  Tirok,  are  of  the  opinion  that  the  first  duty  of  the  mili- 
tary surgeons  when  in  action  consists  in  concentrating  their  energies 
in  providing  for  a  speedy  removal  of  the  wounded  from  the  firing- 
line  to  a  place  of  safety.  It  is  their  belief  that  little  or  nothing  can 
be  done  in  the  way  of  treating  wounds  until  this  has  been  accom- 
plished. Many  of  the  military  surgeons  have  recently  expressed 
themselves  as  being  opposed  to  the  employment  of  the  first-aid 
package  by  any  but  medical  men.  This  position  will  be  found 
untenable  during  any  great  war,  when  the  number  of  wounded 
would  greatly  exceed  the  working  capacity  of  the  limited  number 
of  surgeons.  Additional  and  equally  strong  arguments  against 
such  limitation  of  the  first-aid  dressing  behind  the  firing-line  are 
the  well-known  facts  that  the  sooner  a  recent  wound  is  properly 
dressed,  the  greater  is  the  probability  of  its  remaining  practically 
a.septic,  and  that  the  simple  dressing  proposed  here  can  be  effi- 
ciently applied  by  any  person  of  average  intelligence  who  can  be 
made  to  understand  and  follow  the  imperative  rule  never  to  touch 
the  wound.  Every  soldier  must  be  taught  the  danger  of  hand 
contact  and  the  importance  of  the  first-aid  dressing  and  its  manner 
of  application.  The  trained  hospital  corps  men  of  the  future  can 
be  intrusted  with  this  part  of  the  field  service.  I  am  confident  that 
the  prompt  first-aid  dressing  applied  by  well-instructed  hospital 
corps  men  and  litter  bearers  will  do  more  to  prevent  wound  infec- 
tion than  the  delayed  dres.sings  in  skilled  hands.  Tiie  clothing  of 
the  patient,  if  allowed  to  remain  in  contact  with  the  wound  for  any 
length  of  time,  is  a  very  serious  source  of  infection,  probably  nearly 
on  a  par  with  hand  contact,  and  the  sooner  the  wound  is  protected 
from  it  by  the  first-aid  dressing,  the  greater  will  be  tiie  chances  of 
preventing  infection.  I  fully  agree  with  those  who  are  oppo.sed  to 
the  removal  of  clothing  from  the  wounded  part  in  the  firing-line 
for  the  purpose  of  inspecting  and  dressing  the  wound.  The 
wounded  must  be  removed  to  a  place  of  safety  as  promptly  as  pos- 


240  GUNSHOT    WOUNDS. 

sible.  The  first-aid  dressing  can  be  applied  in  a  few  moments 
without  the  removal  of  any  of  the  clothing  except  the  shoes  or 
boots  in  dressing  wounds  of  the  foot  or  lower  part  of  the  leg.  In 
gunshot  wounds  of  the  extremities  the  seam  of  the  trousers  can  be 
sufficiently  ripped  to  expose  the  wound,  and  the  underclothing  can 
be  cut  to  the  requisite  extent  to  expose  the  wound  or  wounds  suf- 
ficiently for  the  application  of  the  first-aid  dressing.  The  dressing 
is  fixed  in  place  with  strips  of  adhesive  plaster,  and  the  retaining 
bandage  should  be  applied,  not  under,  but  over,  the  clothing.  In 
dressing  wounds  of  the  chest,  abdomen,  and  pelvis  the  dressing 
and  bandage  are  applied  in  a  similar  manner.  In  gunshot  fractures 
of  the  extremities  an  extemporized  fixation  dressing  of  the  simplest 
kind  completes  the  first  aid,  and  prepares  the  patient  properly  for 
transportation  to  the  rear.  The  value  of  the  first-aid  dressing 
became  very  apparent  during  the  Cuban  and  Porto  Rican  cam- 
paigns. One  thing  that  was  supplied  liberally  and  timely  by  the 
Medical  Department  was  first-aid  dressings,  and  to  this  we  must 
largely  attribute  the  speedy  healing  of  most  of  the  gunshot  injuries 
and  the  few  wound  complications  which  later  required  operative 
interference.     In  conclusion  I  would  emphasize  the  following  : 

1.  First-aid  packages  are  indispensable  on  the  battle-field  in 
modern  warfare. 

2.  The  first-aid  dressing  must  be  sufficiently  compact  and  light 
to  be  carried  in  the  skirt  of  the  uniform  or  on  the  inner  surface  of 
the  cartridge  or  sword  belt,  so  as  to  cause  no  inconvenience  to  the 
soldier  or  conflict  with  military  regulations. 

3.  The  Esmarch  triangular  bandage  is  of  great  value  in  the 
school  of  instruction  ;  as  a  component  part  of  the  first-aid  package 
it  is  inferior  to  the  gauze  bandage. 

4.  The  first-aid  package  must  contain,  in  a  waxed  aseptic 
envelop,  an  antiseptic  powder,  such  as  borosalicylic  powder ;  two 
strips  of  aseptic  lintin,  4  by  8  inches  ;  a  gauze  handkerchief  40 
inches  square  ;  sterilized  pins  wrapped  in  tin-foil  ;  and  between  this 
package  and  the  outside  impermeable  cover  two  strips  of  adhesive 
plaster  i  inch  wide  and  8  inches  long. 

5.  The  first-aid  dressing  must  be  applied  as  soon  after  the 
receipt  of  the  injuiy  as  possible,  a  part  of  the  field  service  that 
can  be  safely  intrusted  to  competent  hospital  corps  men. 

6.  The  first-aid  dressing,  if  employed  behind  the  firing-line, 
should  be  applied  without  removal  of  the  clothing  over  the  injured 
part,  and  should  be  fastened  to  the  surface  of  the  skin  with  strips 
of  rubber  adhesive  plaster,  the  bandage  being  applied  over  and  not 
under  the  clothing. 

7.  The  first-aid  dressing  must  be  dry,  and  should  remain  so  by 
dispensing  with  an  impermeable  cover  of  any  kind  over  it,  so  as 
not  to  interfere  with  free  evaporation  of  the  wound  secretion. 

8.  The  first-aid  dressing  should  not  be  disturbed  unnecessarily, 
but  any  defects  should  be  corrected  at  the  first  dressing  station. 


CHANGES    IN    CHARACTER    OF    WOUNDS.  24 1 

In  the  remaining  part  of  this  section  there  will  be  some  repe- 
titions, but  these  are  concise  and  are  made  with  special  reference  to 
military  surgery. 

Two  important  causes  were  destined  to  bring  about  a  radical 
change  in  the  treatment  of  gunshot  wounds  as  practised  in  the  Civil 
War,  as  was  taught  and  advised  in  the  Spanish- American,  and 
will  be  practised  in  future  wars  :  (i)  The  modifications  that  weapons 
and  projectiles  have  undergone  since  that  time  ;  (2)  the  introduction 
into  general  practice  of  aseptic  and  antiseptic  surgery.  The  dimi- 
nution in  the  caliber  of  the  bullet,  the  metallic  jacket,  the  substitu- 
tion of  smokeless  for  black  powder,  the  greater  velocity  and  power 
of  penetration  of  the  missile,  are  conditions  and  influences  that  must 
necessarily  modify  the  character  of  wounds  inflicted  with  the  modern 
weapon.  Volumes  have  been  written  on  this  subject  by  writers  in 
all  countries  in  which  the  old  weapon  has  been  abandoned  and  the 
new  one  introduced.  Numerous  experiments  have  been  made  on 
cadavers  and  on  animals  for  the  purpose  of  studying  the  effects  of 
the  modern  projectile  on  the  tissues,  with  a  view  to  obtaining  re- 
liable information  as  to  the  changes  that  will  become  necessary  in 
the  rational  treatment  of  gunshot  wounds  in  modern  warfare.  Ex- 
perimental investigation  has  done  much  to  point  out  some  of  the 
changes  we  may  expect  to  see  in  the  character  of  gunshot  wounds 
during  coming  wars,  but  many  of  the  conclusions  drawn  from  them 
will  have  to  be  modified  after  we  have  had  an  opportunity  to  study 
such  wounds  on  a  larger  scale  on  the  battle-field.  There  can  be 
no  question  but  that  the  living  body  and  the  cadaver  represent  two 
entirely  different  media  in  studying  the  effects  of  the  modern  bullet. 
From  a  practical  standpoint  there  remains  no  doubt  as  to  the  fol- 
lowing facts,  which  will  be  confirmed  by  future  experience  in  the 
treatment  of  gunshot  injuries  inflicted  with  the  small-caliber  bullet: 
(i)  Fewer  bullets  will  be  found  lodged  in  the  body.  (2)  Wounds 
will  resemble  more  closely  incised  than  contused  wounds.  (3) 
Range  will  have  more  influence  in  changing  the  character  of  the 
wound.  (4)  Diminished  risk  of  infection.  (5)  Dangerous  primary 
hemorrhage  will  be  more,  secondary  hemorrhage  less,  frequent. 
(6)  More  difificult  extraction  of  the  bullet.  The  relative  num- 
ber of  dead  and  wounded  and  the  adaptation  of  the  jacketed 
bullet  to  become  encysted  are  subjects  that  have  been  fairly  well 
elucidated  during  the  Cuban  campaign,  but  that  must  be  more 
definitely  settled  by  wider  experience.  We  are  better  prepared  to 
predict  the  influence  wrought  by  the  recent  discoveries  and  advance- 
ments in  surgery  on  the  treatment  of  gunshot  wounds  and  the  fate 
of  the  wounded.  The  antiseptic  treatment  of  wounds  as  taught  and 
I^ractised  by  the  immortal  Lister,  and  asepsis  as  developed  by  the 
German  surgeons,  with  the  di.stinguished  Volkmann  and  Nus.sbaum 
as  their  leaders,  are  destined  to  minimize  the  remote  dangers  of 
gun.shot  wounds  and  other  open  injuries  inflicted  on  the  battle- 
field. I  can  .safely  repeat,  with  the  late  Profe.s.sor  von  Nus.sbaum, 
16 


242 


GUNSHOT    WOUNDS. 


the  most  enthusiastic  follower  of  Lister  :  "  The  fate  of  the  wotaided 
rests  in  the  hands  of  the  07ie  who  applies  the  first  dressing.''  This  is 
the  motto  that  every  military  surgeon  must  adopt  and  carry  into 
effect.  To  this  motto  I  would  like  to  add  the  inflexible  rule,  which 
should  never  be  transgressed  and  which,  if  observed  without  ex- 
ception, will  guard  against  one  of  the  most  fruitful  sources  of  infec- 
tion, and  that  rule  should  be  :  Never  probe  a  bidlet  zvojind  on  the 
battlefield.  The  experience  of  the  past  has  taught  us  the  wisdom 
of  adopting  such  a  universal  rule.  In  wounds  inflicted  by  the  small- 
caliber  bullet  the  cases  will  be  few  where  there  is  any  indication  for 
probing  wounds,  and  in  those  few  where  the  bullet  has  lodged  in 
the  body   exploration   should   be    absolutely  prohibited   until   the 


Fig.  143. — Immobilization  of  arm 
and  forearm  by  fastening  the  sleeve  to 
the  coat  near  the  wrist-  and  elbow-joints 
with  safety-pins,  and  inserting  hand  un- 
derneath coat  on  opposite  side  between 
two  buttons. 


Fig.  144. — Mitella  by  fastening  skirt 
of  coat  on  injured  side  with  two  safety- 
pins,  in  such  a  position  as  to  support  the 
forearm  in  a  flexed  position. 


patent  reaches  the  field-hospital,  where  the  facilities  for  asepsis  are 
at  hand  and  instruments  of  precision  in  diagnosis  can  be  employed 
in  locating  the  missile. 

In  the  absence  of  grave  symptoms,  such  as  hemorrhage,  the 
first  dressing  should  not  be  disturbed  until  the  patient  reaches  the 
field-hospital,  and  in  many  cases  healing  of  the  wound  will  take 
place  without  further  interference.  The  immobilization  of  the  injured 
part,  particularly  in  cases  of  compound  fracture  of  the  extremities, 
constitutes  an  important  part  of  the  manifest  duties  of  those  who 
render  first  aid  to  the  wounded.  In  all  large  engagements  the  sup- 
ply of  mechanical  supports  carried  by  the  men  of  the  hospital  corps 


IMPROVISED    SPLINTS. 


243 


will  be  exhausted  long  before  all  the  wounded  have  received  atten- 
tion. Splints  must  be  improvised.  Rifles,  sabers,  bayonets,  bark, 
branches  of  trees,  shrubs,  etc.,  the  chest  in  fractures  of  the  upper 
extremity,  the  opposite  limb  in  fractures  of  the  thigh  or  leg,  will 
have  to  be  utilized  in  procuring  rest  for  the  injured  limb  in  trans- 
porting patients  from  the  line  of  battle  to  the  first  dressing  station. 
It  is  here  that  the  surgeons  will  supplement  or  improve  the  work 
done  by  the  litter  bearers  and  hospital  corps.  It  is  for  the  purpose 
of  doing  awa}'  with  the  necessity  of  using  splints  that  a  German  mili- 
tary surgeon   has   recently  devised  a  litter  on  the  plan  of  a  double 


Fig.  145. — Saber  splint  for  leg  and  thigh. 


Fig.  146. — Gun  splint. 


Fig.  147. — .Stick  and  blanket  splint. 


inclined  plane  for  the  lower  extremities,  a  description  of  which  he 
gave  before  the  military  section  of  the  International  Medical  Con- 
gress held  in  Moscow  last  summer.  In  the  absence  of  a  litter  of 
such  special  construction  the  same  object  is  attained  by  securing 
the  .same  position  for  the  injured  limb  by  a  roll  made  of  a  blanket, 
clothing,  knapsack,  drum,  straw,  etc.  It  is  my  opinion  that  the 
transportation  of  the  wounded  suffering  from  a  fracture  of  the  lower 
extremity  can  be  done  with  less  pain  and  with  greater  .security 
again.st  additional  injuries  if  the  fractured  limb  is  placed  in  a  flexed 
than  if  placed  in  a  straight  position.      If  this  statement  is  found  to 


244 


GUNSHOT    WOUNDS. 


be  correct  by  future  observations,  the  manner  of  dressing  such  cases 
must  undergo  a  material  change  in  the  future.  The  manner  of 
handling,  carrying,  and  conveying  patients  suffering  from  fracture 
of  the  lower  extremity  from  the  field  to  the  hospital  is  a  subject  of 
great  importance  to  those  who  have  in  charge  the  instruction  of  the 
hospital  corps  and  company  bearers. 

Arrest  of  Hemorrhage  on  the  Field. — Life  will  be  placed  in 
jeopardy  and  deaths  will  occur  more  frequently  from  internal  than 
from  external  hemorrhage  ;  in  the  treatment  of  the  former  little  can 
be  done  on  the  field,  and  the  latter  class  will  come  more  frequently 
under  the  care  of  nonprofessional  men  than  surgeons.      Ligation  of 

arteries  on  the  field  will  prove 
impracticable  in  most  instances. 
The  company  bearers  and  hos- 
pital corps  men  should  be  fully 
instructed  in  the  details  of  the 
various  hemostatic  resources 
applicable  in  emergency  work. 
Elevation  of  the  injured  part, 
hyperflexion,  digital  compres- 
sion, and  antiseptic  tamponade 
are  some  of  the  measures  em- 
ployed that  can  be  intrusted  to 
intelligent  and  well-instructed 
laymen  in  arresting  hemor- 
rhage. 

Elastic  Constriction. — 
Some  form  of  circular  constric- 
tion will,  however,  most  fre- 
quently be  relied  upon  in  ar- 
resting hemorrhage  complicat- 
ing gunshot  wounds  of  the  ex- 
tremities. The  advantages  and 
dangers  attending  this  method 
of  arresting  hemorrhage  must 
be  made  a  prominent  feature  in 
giving  instructions  in  first  aid. 
The  technic  of  the  procedure,  whether  it  consists  in  the  use  of  the 
typical  Esmarch's  elastic  constrictor,  a  pair  of  suspenders,  or  the 
Spanish  windlass,  must  be  fully  explained  and  demonstrated  on  the 
living  subject.  The  fact  must  be  impressed  that  it  is  of  great  im- 
portance to  render  the  limb  that  is  to  be  constricted  comparatively 
bloodless  by  elevation  before  the  constrictor  is  applied.  The  next 
most  important  advice  to  be  carried  into  effect  in  the  use  of  circular 
constriction  is  to  constrict  quickly  and  zvith  sufficient  firmness  to 
interrupt  at  once  and  completely  both  the  arterial  and  the  venous  cir- 
culation. A  question  of  immense  and  far-reaching  importance,  and 
one  that  has  not  as  yet  been  definitely  answered,  is  :  How  long  is  it 


Fig.  148.- 


-Bark  splint  for  forearm  and  wire 
splint  for  arm. 


ARREST    OF    HEMORRHAGE. 


245 


safe  to  continue  the  constriction  ?  There  must  be,  and  there  is,  a 
limit  as  to  length  of  time  it  is  safe  to  exclude  blood  supply  from 
living  tissues.  Although  cases  have  been  reported  in  which  elastic 
constriction  was  continued  for  from  three  to  twelve  hours  without 
any  serious  immediate  or  remote  consequences  following,  yet  the 
consensus  of  opinion  among  surgeons  at  the  present  time,  I  am 
sure,  would  be  opposed  to  excluding  the  blood  supply  from  an  entire 
limb,  the  seat  of  a  gunshot  injury,  for  a  longer  time  than  three  or 
four  hours.  The  danger  of  gangrene  is  always  greater  in  constrict- 
ing an  injured  than  a  healthy  limb.  A  number  of  years  ago  I 
made  an  extended  series  of  experiments  on  dogs,  detailed  more 
fully  elsewhere,  to  determine,  if 
possible,  the  maximum  length  of 
time  it  would  be  safe  to  continue 
elastic  constriction.  The  limb  was 
invariably  constricted  near  its  base. 
The  time  varied  from  an  hour  and 
a  half  to  twenty-seven  hours.  In 
a  number  of  cases  temporary  in- 
competence of  the  muscles  and 
temporaiy  paralysis  followed  when 
constriction  was  continued  beyond 
four  hours,  but  the  degree  of  func- 
tional disturbance  was  not  always 
proportionate  to  the  length  of  time. 
In  only  one  instance  did  gangrene 
occur,  and  in  this  case  constriction 
was  continued  for  seventeen  hours, 
while  the  maximum  time  was 
twenty-seven  hours.  This  subject 
is  of  special  interest  to  the  military 
surgeon,  as  from  the  very  nature 
of  things,  if  circular  constriction  is 
resorted  to  as  a  hemostatic  agent 
on  the  battle-field,  a  considerable 
length  of  time  must  necessarily  in- 
tervene before  the  wounded  reach 
the  first  dressing  .station  or  field- 
hospital,  where  it  is  removed  and  hemorrhage  arrested  by  direct 
and  permanent  hemostatic  measures.  I  should  consider  it  danger- 
ous to  extend  the  time  beyond  from  three  to  six  hours,  and  should 
in.sist  that  within  this  limit  of  time  the  patient  sh-ould  be  placed  in 
charge  of  a  surgeon  fully  equipped  to  substitute  for  it  the  ligature, 
aseptic  tamponade,  or  some  other  direct  hemostatic  agent. 

Elevation  of  Limb. — The  force  of  gravitation  answers  an  ex- 
ceedingly useful  purpo.se  in  arresting  hemorrhage  from  the  smaller 
vessels  of  the  extremities.  By  placing  the  injured  limb  in  a  vertical 
position,  intravascular  pressure  is  so  much  diminished  that  sponta- 


Fig.  149. — Forced  flexion  of  fore- 
arm in  arresting  hemorrhage  from  the 
bracliial  artery  opposite  the  elbow-joint 
or  any  of  its  branches  below  this  point. 


246 


GUNSHOT    WOUNDS. 


neous  arrest  of  hemorrhage  is  often  effected  by  this  simple  proce- 
dure, even  when  a  vessel  the  size  of  the  palmar  arches  is  injured, 
but  its  greatest  value  and  widest  range  of  application  will  be  in  the 
treatment  of  venous  and  parenchymatous  hemorrhage.  The  ele- 
vated position  should  be  maintained  for  some  time  after  the  hemor- 
rhage has  ceased,  or  until  more  efficient  measures  can  be  employed. 
The  manner  of  effecting  and  maintaining  elevation  as  a  hemostatic 
agent  is  shown  in  figures  19  and  20. 

Digital  Compression. — In  the  treatment  of  hemorrhage  from 
large  vessels  accessible  to  digital  compression  this  method  offers  a 
reliable  means  of  controlling  hemorrhage.  The  members  of  the 
hospital  corps  are  familiarized  with  the  exact  location  of  the  princi- 
pal arteries  of  the  extremities  and  the  method  of  arresting  hemor- 
rhage by  digital  compression. 

The  compression  must  be  continued  uninterruptedly  until  the 
bleeding  vessel  can  be  tied,  or  pressure  can  be  replaced  by  elastic 
constriction  or  the  antiseptic  tampon. 


Fig.  150. — Genuflexion  in  the  treatment  of  hemorrhage  from  the  pophteal  artery 

and  its  branches. 


Flexion. — Forced  flexion  as  a  hemostatic  agent  was  introduced 
by  Adelmann.  Genuflexion  is  a  prompt  and  efficient  method  of 
arresting  hemorrhage  from  the  popliteal  artery  and  its  branches. 
Brachial  hyperflexion  answers  the  same  purpose  in  the  treatment 
of  hemorrhage  from  the  brachial  artery  from  a  point  opposite  the 
elbow-joint  or  any  of  its  branches  below  this  point.  In  making 
genuflexion  the  belt,  a  suspender,  a  gunstrap,  or  a  triangular  band- 
age should  be  passed  through  a  slit  in  the  shoe  or  boot  above  the 
heel,  after  which  the  ends  are  firmly  tied  over  the  base  of  the 
thigh,  when  it  is  fastened  to  the  trousers  or  drawers  with  a  safety- 
pin.  Forced  flexion  of  the  forearm  can  be  made  with  an  ordinary 
handkerchief 

Antiseptic  Tampon. — The  antiseptic  tampon  is  a  convenient 
and  very  useful  hemostatic  agent  in  the  treatment  of  accidental 
hemorrhage.  The  antiseptic  package  with  which  every  soldier  of 
civilized  warfare  Avill  be  supplied  can  be  used  advantageously  for 
this  purpose.      It  will  prove  of  special  value  in  the  arrest  of  hem- 


INTERNAL    HEMORRHAGE. 


247 


orrhage  from  the  vessels  of  the  scalp,  face,  and  intercostal  arteries, 
and  in  the  treatment  of  open  lacerated  and  saber  wounds.  The 
surface  to  be  compressed  should  be  dusted  with  the  antiseptic 
powder  contained  in  the  package,  and  with  the  hygroscopic  anti- 
septic material  composing  the  remainder  of  the  package  a  gradu- 
ated compress  is  made,  the  apex  of  which  is  placed  in  contact  with 
the  bleeding  vessel,  and  the  necessary  degree  of  pressure  secured 
by  a  circular  bandage,  with  or  without  the  use  of  an  extemporized 
splint,  according  to  the  location  of  the  vessel  or  the  relations  of 
the  injured  vessel  to  the  underlying  bone. 

Vessel  injuries  treated  by  antiseptic  tamponade  will  seldom 
require  ligation,  as  the  tampon,  if  the  wound 
remains  aseptic,  is  allowed  to  remain  until 
the  lumen  of  the  injured  vessel  or  vessels 
becomes  obliterated  permanently  by  throm- 
bosis and  cicatrization. 

Internal  Hemorrhage. — The  prompt  and 
proper  treatment  of  internal  hemorrhage  will 
constitute  one  of  the  crowning  triumphs  of 
surgery  upon  the  battle-field.  The  direct 
treatment  of  the  wounded  vessels  by  early 
invasion  of  any  of  the  large  cavities  of  the 
body  will  be  the  means  of  saving  many  lives 
that  would,  heretofore,  have  been  doomed  to 
certain  death.  This  part  of  the  surgeon's 
work  will  be  done  at  the  first  dressing  station 
or  at  the  field-hospital.  What  can  be  done 
behind  the  fighting-line  in  such  cases  to 
bridge  over  the  time  until  such  services  can 
be  rendered  to  the  injured?  In  hemorrhage 
from  the  intracranial  vessels  caused  by  bullet 
wounds,  it  would  be  dangerous  to  plug  the 
wounds  of  entrance  and  exit,  as  the  accumu- 
lation of  blood  in  the  cranial  cavity  would 
result  in  death  from  cerebral  compression. 
The  escape  of  blood  should  be  favored  by 
inserting  into  the  track  made  by  the  bullet  a 

strip  of  aseptic  or  iodoform  gauze.  This  will  not  only  serve  a  use- 
ful purpose  as  a  capillary  drain,  but,  by  bringing  an  aseptic  foreign 
substance  in  contact  with  the  injured  vessels,  the  spontaneous  arrest 
of  hemorrhage  by  thrombosis  is  favored.  The  gauze  drain  should 
be  secured  on  the  surface  of  the  wound  with  a  safety-pin,  and  the 
wound  or  wounds  protected  against  infection  by  an  antiseptic 
dressing,  retained  in  place  by  the  triangular  bandage.  By  this 
treatment  many  cases  will  reach  the  field-hospital  for  a  timely 
intracranial  operation.  In  bullet  and  stab  wounds  of  the  chest 
complicated  by  hemorrhage  fr(jm  the  intercostal  arteries  the  anti- 
septic tampon   is   the  proper  treatment.      Packing  of  the   tubular 


Fig.  151.  —  Tempo- 
rary treatment  of  penetrat- 
ing wound  of  chest  by 
antiseptic  tamponade  and 
immobilization  by  circular 
compression. 


248 


GUNSHOT    WOUNDS. 


wound  with  an  antiseptic  hygroscopic  material  will  not  only  suc- 
ceed in  arresting  the  hemorrhage,  but  will  serve  at  the  same  time 
as  an  efficient  capillary  drain  and  protect  the  cavity  of  the  chest 
and  its  contents  against  infection.  In  hemorrhage  from  injuries  of 
the  organs  of  the  chest,  firm  circular  compression  of  the  chest 
directly  over  the  wound,  already  protected  against  infection  by 
an  antiseptic  dressing,  constitutes  a  valuable  indirect  hemostatic 
measure. 

Immobilization  of  the  chest-wall  by  circular  compression  dimin- 
ishes the  functional  activity  of  the  lungs,  and  in  doing  so  exerts  a 
favorable  influence  in  arresting  hemorrhage  from  this  organ.  The 
cartridge  belt  or  gunstrap  can  be  used  to  the  greatest  advantage  in 
limiting  the  respiratory  movements  of  the  chest.  I  believe  that 
this  conservative  treatment  of  penetrating  wounds  of  the  chest 
will  yield  better  results  than  the  injection  of  filtered  air,  absorbable 
aseptic  solutions,  or  treatment  by  rib  resection,  free  incision,  and 
attempts  to  ligate  the  bleeding  vessels.  In  penetrating  wounds  of 
the  abdomen  the  prime  indication  in  the  future  treatment  of  such 
injuries    will    be    to    prevent    death    from    hemorrhage.      Visceral 


152. — Compression  of  abdominal  aorta  (Esmarch). 


wounds  of  the  abdominal  organs,  notably  the  liver,  spleen,  and 
mesentery,  usually  give  rise  to  profuse  and  often  fatal  hemorrhage. 
The  hemorrhage  is  more  frequently  venous  and  parenchymatous 
than  arterial.  In  my  address  before  the  Association  of  the  Mili- 
tary Surgeons  of  the  United  States  on  one  occasion,  I  urged  the 
importance  of  early  operative  interference  in  such  cases,  and  men- 
tioned hemorrhage  and  the  direct  treatment  of  visceral  wounds  as 
ample  indications  to  justify  prompt,  active  interference.  In  injuries 
of  vessels  below  the  bifurcation  of  the  abdominal  aorta  attempts 
should  be  made  to  prevent  death  from  hemorrhage  upon  the  battle- 
field by  resorting  to  the  use  of  compression,  with  a  view  to  inter- 
rupting the  circulation  in  the  aorta  above  the  bleeding  point. 
Esmarch's  method,  shown  in  figure  152,  can  be  extemporized  in  a 
few  moments,  as  it  requires  no  instruments  of  special  construction 
and  meets  the  indications  more  completely  than  the  various  instru- 
ments devised  for  the  same  purpose.  The  method  of  Brandis  is 
equally  simple  and  efficacious.  As  hemorrhage  from  any  of  the 
vascular  organs  and  large  vessels  of  the  abdominal  viscera  requires 


PERMANENT    HEMOSTASIS.  249 

prompt  treatment,  and  as  in  large  engagements  a  considerable 
length  of  time  will  necessarily  intervene  between  the  first-aid  and 
the  permanent  arrest  of  hemorrhage  by  laparotomy,  and  as  in 
many  instances  the  location  of  the  wound  is  outside  of  the  range 
of  successful  treatment  by  compression  of  the  abdominal  aorta.^it 
appears  to  me  that  in  such  cases  it  would  be  good  treatment  to 
resort  to  direct  and  circular  compression,  as  has  been  described  in 
connection  with  penetrating  wounds  of  the  chest.  The  wound 
of  entrance  and  of  exit,  if  the  latter  exists,  should  be  protected  by 
an  antiseptic  dressing.  Over  the  wound,  corresponding  with  the 
yielding  part  of  the  abdominal  wall,  a  large  compress,  which  may 
be  composed  of  a  compress  made  of  a  blanket,  an  article  of  cloth- 
ing, a  cartridge  belt,  or  a  canteen,  should  be  placed,  and  over  it 
firm  circular  compression  made  with  a  belt  or  gunstrap.  The 
direct  compression  made  in  the  direction  of  the  track  of  the  bullet 
will  do  much  toward  diminishing  the  vascularity  of  the  undcrl}-ing 
injured  parts,  while  the  circular  compression  will  immobilize  the 
abdominal  wall  at  the  seat  of  injury  and  limit  the  movements  of  the 
abdominal  organs,  conditions  which  can  not  fail  to  materially  dimin- 
ish the  risks  of  hemorrhage  and  to  aid  thrombosis,  nature's  re- 
source in  effecting  spontaneous  arrest  of  hemorrhage. 

Permanent   Hemostasis. — Forciprcssiirc. — The  best  and  most 
successful  military  surgeon  is  the  one  who  accomplishes  the  most 
with  the   least  number  of   instruments.      Complicated    instrument 
cases  look  well  and  make  a  favorable  impression  upon  laymen,  and 
can   be  used   to   advantage   in  a  well-equipped   hospital  ;  they  are 
out  of  place  on  the  battle-field.      The  fewer  the  instruments  in  the 
treatment  of  emergency  cases,  the  less  the  danger  of  infection.      I 
have  recently  devised  an  operating  pocket-case  that  contains  all  the 
instruments  a  military  surgeon  is  expected  to  use  when  in  active 
service.      It  contains,  among  the  instruments  needed  for  emergency 
work,  seven  hemostatic  forceps,  b)^  the  use  of  which  he  is  in  a  posi- 
tion  to  meet    the  emergencies  incident    to  hemorrhage    upon  the 
battle-field.      The  u.se  of  aseptic  hemostatic  forceps  upon  the  battle- 
field will  meet  the  indications  successfully  in  many  cases  in  which 
other  hemostatic  measures  are  inapplicable.      If  the  bleeding  vessel 
IS  so  located  that  it  can  be  grasped  with  hemostatic  forceps  but  can 
not  be  ligated  without  performing  a  formidable  operation,  the  forceps 
should  be  allowed  to  remain  and  should  be  incorporated  in  the  anti- 
septic dres.sing,  and  a  note  be  made  to  this  effect  on  the  diagnosis 
tag. 

Ligati07i. — Ligation  of  blood-vessels,  arteries,  and  veins  will 
usually  be  done  upon  the  battle-field  after  temporary  hemostasis  by 
other  means,  either  at  the  first  dressing  station  or.  more  frequently, 
at  the  field-hospital.  Silk  is  the  proper  ligature  material  in  military 
service.  It  can  be  .sterilized  repeatedly  by  boiling,  and  is,  conse- 
quently, a  much  .safer  material  than  catgut  in  emergency  practice. 
A.septic   silk   in   an    aseptic    wound    invariably   becomes  encysted. 


250  GUNSHOT    WOUNDS. 

Catgut  sterilized  in  Boeckmann's  sterilizer  and  kept  ready  for  use 
in  sterilized  envelops,  as  advised  by  Boeckmann,  could  be  made 
serviceable  for  military  surgery.  As  a  rule,  the  vessel  should  be 
tied  at  the  seat  of  injury  by  enlarging  the  existing  wound  and 
using  it  as  a  guide  to  the  injured  vessel.  Cases,  however,  will 
present  themselves  in  which  it  is  impossible  to  apply  this  rule,  and 
in  which  the  artery  must  be  tied  in  its  continuity  in  a  more  acces- 
sible place  on  the  proximal  side  of  the  bleeding  point.  Antiseptic 
precautions  in  the  treatment  of  wounds  and  in  the  employment  of 
the  aseptic  ligature  will  materially  diminish,  if  not  entirely  over- 
come, the  risk  of  secondary  hemorrhage,  which  proved  such  a 
terror  to  the  surgeons  and  so  frequent  a  source  of  danger  and 
death  to  the  injured  during  the  great  Civil  War.  The  ligature 
should  never  be  tied  sufficiently  tight  to  rupture  any  of  the  tunics 
of  the  vessel.  All  that  is  necessary  to  obtain  an  ideal  permanent 
obliteration  of  the  vessel  is  to  approximate  and  hold  the  intima  in 
uninterrupted  contact.  If  the  vessel  requiring  ligation  in  its  con- 
tinuity is  a  large  one,  a  double  ligature  with  a  bloodless  space 
between  the  two  ligatures  is  preferable,  as  the  space  interposed 
between  them  offers  the  most  favorable  conditions  for  an  early  and  a 
permanent  obliteration  of  the  lumen  of  the  vessel.  Under  aseptic 
and  antiseptic  precautions  the  ligation  of  large  veins  is  as  safe  a 
procedure  as  ligation  of  the  accompanying  arteries. 

Vein  Suture  and  Lateral  Ligation. — In  small  wounds  of  large 
veins  lateral  ligation  and  suturing  with  fine  silk  or  catgut  secure 
permanent  hemostasis,  with  preservation  of  the  lumen  of  the  vein, 
and  for  these  reasons  should  receive,  in  this  kind  of  vein  injuries, 
the  preference  to  ligation  in  continuity.  This  method  of  treatment 
is  of  particular  value  in  the  case  of  wounds  of  the  superior  longi- 
tudinal sinus  and  the  large  veins  at  the  base  of  the  neck,  in  the 
axillae  and  the  groins,  as  well  as  the  large  veins  in  the  abdominal 
cavity.  The  lateral  ligature  is  applied  by  seizing  the  margins  of  the 
vein  wound  with  a  sharp  tenaculum,  and  tying  the  base  of  the  cone 
with  a  fine  silk  or  catgut  ligature.  In  suturing  of  vein  wounds  the 
margins  are  inverted  toward  the  lumen  of  the  vessel  in  the  same 
manner  as  in  closing  an  intestinal  wound  by  Lembert's  sutures. 

Hot  Water  and  Styptics. — Hot  water  at  a  temperature  of  from 
120°  to  130°  F.  coagulates  the  albumin  upon  the  surface  of  the 
wound,  and  in  doing  so  seals  the  orifices  of  small  vessels  ;  on  this 
account  it  has  become  a  popular  hemostatic  in  arresting  parenchy- 
matous bleeding  in  parts  and  organs  accessible  to  this  method  of 
treatment.  The  employment  of  styptics  in  arresting  hemorrhage, 
on  the  whole,  should  be  discountenanced,  as  their  use  interferes 
with  an  ideal  healing  of  the  wound.  Their  application  can  only  come 
in  question  in  the  treatment  of  bleeding  wounds  of  the  mouth  and 
pharynx,  where  antiseptic  tamponade  is  impracticable. 

Saline  Lnfusion. — Patients  who  have  become  debilitated  by 
hemorrhage  to  the  extent  of  endangering  life  require  restoration  of 


AUTOTRANSFUSION.  25  I 

a  normal  degree  of  intracardiac  and  intrav^ascular  pressure  by  saline 
infusion.  Transfusion  of  blood,  whole  or  defibrinated,  has  been 
clinicalK'  and  experimentally  proved  a  failure  in  preventing  death 
from  the  immediate  and  remote  results  of  dangerous  hemorrhage. 
The  transfused  morphologic  elements  of  the  blood  do  not  retain 
their  vitality,  and  are  destined  to  be  removed  from  the  receiver 
sooner  or  later  by  elimination  through  some  of  the  excretory  organs. 
Von  Bergmann  and  others  have  shown  that  the  immediate  cause  of 
death  from  acute  hemorrhage,  subnormal  intracardiac  and  intra- 
vascular pressure,  can  be  avoided  more  successfully  by  substituting 
a  ph}-siologic  solution  of  common  salt  for  animal  or  human  blood. 
Every  field  outfit  should  be  supplied  with  a  definite  quantity  of 
salt,  from  which  the  solution  can  be  prepared  in  a  few  moments. 
Szumann's  solution  is  especially  well  adapted  for  this  purpose.  It 
consists  of: 

Natr.  chlorid,      6  parts 

Natr.  carbon., I  part 

Aq.  destillat., 1 000  parts. 

The  chlorid  and  carbonate  of  soda  in  the  foregoing  proportion 
should  be  carried  in  every  pannier,  so  as  to  be  available  in  all 
cases  in  which  a  saline  infusion  may  become  necessary.  The 
simplest  apparatus  for  making  a  saline  infusion  is  a  glass  or  hard- 
rubber  funnel,  with  two  or  more  feet  of  rubber  tubing  and  a  small 
glass  tube  with  a  tapering  point.  The  median  basilic  vein  is  usually 
selected  for  making  the  infusion. 

The  vein  is  exposed  by  a  small  incision,  after  having  rendered 
it  turgid  by  proximal  compression  in  the  same  manner  as  in  per- 
forming phlebotomy.  After  exposure  of  the  vein  it  is  incised  trans- 
versely and  the  point  of  the  glass  tube  inserted  and  fastened  in  place 
by  a  ligature  previously  inserted  (see  Fig.  84).  Before  inserting 
the  glass  tube,  the  precaution  should  be  taken  to  fill  it  and  the 
rubber  tube  with  the  saline  solution,  to  prevent  the  introduction  of 
air.  The  saline  solution  to  be  used  should  be  heated  slightly  over 
the  tem[)erature  of  the  blood,  and  infection  is  prevented  by  using 
only  sterilized  water  for  the  solution. 

The  quantity  of  solution  to  be  used  will  var}^  from  500  to  i  500 
gm.,  1000  gm.  being  a  fair  average  dose,  and  for  the  preparation  of 
which  the  requisite  quantity  of  the  alkaline  powder  should  be  kept 
in  readiness.  If  the  symptoms  of  improvement  that  follow  the 
employment  of  the  saline  infusion  should  come  to  a  standstill  or 
di.sappear,  it  may  become  necessary  to  repeat  the  intravenous  infu- 
sion in  the  course  of  an  hour  or  more. 

The  same  object  gained  by  intravenous  infusions  of  salt  solu- 
tion is  attained  more  indirectly  and  with  greater  loss  of  time  by 
copious  hypodermic  and  rectal  injections. 

Autotransfusion. — In  threatening  danger  to  life  from  hemorrhage 
much  can  be  gained  by  autotransfusion.  The  exclusion  from  the 
general  circulation  of  unessential  parts  of  the  body  will  often  secure 


252  GUNSHOT    WOUNDS. 

for  the  vital  organs  an  adequate  blood  supply.  Autotransfu- 
sion  for  this  purpose  is  secured  promptly  and  efficiently  by  elastic 
constriction  of  one  or  more  extremities  at  their  base.  This  can  be 
accomplished  by  Esmarch's  constrictor,  by  suspenders,  or,  in  the 
absence  of  elastic  material,  by  the  use  of  the  Spanish  windlass  (see 
Fig.  44).  According  to  the  urgency  of  the  symptoms  presented, 
the  base  of  one  or  more  extremities  is  constricted  after  rendering 
the  limb  comparatively  bloodless  by  elevation.  By  exclusion  of 
the  circulation  from  one  or  more  extremities  intravascular  pressure 
compatible  with  essential  functions  is  restored,  and  life  is  bridged 
over  for  a  sufficient  length  of  time  for  the  employment  of  remedies 
of  more  lasting  value. 

Shock. — Next  to  hemorrhage,  shock  should  receive  the  sur- 
geon's attention.  It  is  often  difficult  to  differentiate  between  the 
symptoms  produced  by  shock  and  those  of  hemorrhage.  The  non- 
professional assistant  should  be  made  to  understand  that  the  max- 
imum symptoms  of  shock  are  developed  almost  immediately  after 
the  receipt  of  the  injury,  while  in  hemorrhage  the  intensity  of  the 
symptoms  increases  progressively.  Even  in  a  complete  transverse 
tear  of  an  artery  of  the  size  of  the  common  carotid  it  requires  at  least 
five  minutes  to  produce  death  from  hemorrhage  ;  in  intense  shock 
symptoms  pointing  to  a  fatal  issue  appear  almost  immediately  upon 
the  receipt  of  injury.  Shock  is  the  result  of  a  reflex  vasomotor 
paresis,  and,  consequently,  if  severe,  calls  for  the  most  energetic 
and  prompt  treatment.  A  patient  suffering  from  shock  should  be 
kept  in  the  dorsal  recumbent  position  and  treated  by  active  stimu- 
lation. Inhalations  of  nitrite  of  amyl  and  hypodermic  injections 
of  strychnin  in  doses  of  from  ^  to  -^q  of  a  grain,  repeated  every 
half-hour  until  reaction  takes  place,  constitute  the  most  successful 
treatment.  The  administration  of  alcoholic  stimulants,  camphor, 
and  ammonia  is  also  indicated,  as  well  as  the  external  application 
of  dry  heat.  In  the  transportation  of  patients  suffering  from  shock 
the  greatest  care  should  be  exercised  not  to  subject  them  to  any 
unnecessary  movements,  and  it  is  of  special  importance  that  the 
recumbent  position  should  be  maintained  until  reaction  is  estab- 
lished. No  operation  of  any  considerable  importance  should  be 
performed  until  the  patient  reacts  from  the  immediate  effects  of  the 
injury. 

Primary  Dressing  of  Wound. — Perfect  aseptic  surgery  upon 
the  battle-field  is  a  happy  dream  that  will  probably  never  be  real- 
ized. The  bullets,  as  recent  experiments  have  shown,  are  fre- 
quently contaminated  with  pathogenic  microbes,  and  often  carry 
with  them  infectious  fragments  of  clothing  and  other  foreign  sub- 
stances, as  well  as  microbes  from  the  surface  of  the  injured  part. 
Again,  in  large  battles  the  number  of  wounded  is  so  great  and  the 
number  of  those  to  whom  their  treatment  is  intrusted  is  so  small 
that  the  necessary  antiseptic  precautions  to  obtain  an  antiseptic 
condition  of  the  wound  can  not  always  be  carried  out.      The  duty 


TRANSPORTATION    OF    SICK    AND    WOUNDED.  253 

of  the  surgeon  upon  the  battle-field  in  rendering  the  first  aid  to  the 
wounded,  after  having  given  proper  attention  to  the  treatment  of 
shock  and  hemostasis,  will  be  to  prevent  subsequent  contamination 
of  the  wound  by  protecting  it  with  an  antiseptic  occlusion  dressing. 
Shaving  and  disinfection  of  the  surface  in  the  vicinity  of  the  wound 
are  out  of  the  question  under  such  circumstances.  Search  for 
bullets  and  efforts  to  secure  their  removal  must  be  postponed  until 
the  patient  reaches  the  field-hospital,  where  these  procedures  are 
made  possible  and  the  attending  danger  of  causing  infection  dimin- 
ished by  a  more  complete  instrumentarium  and  more  effective 
means  of  securing  asepticity  of  the  wound  and  its  vicinity.  The 
primary  dressing  on  the  field  has  been  fully  described  in  the  pages 
devoted  to  the  first-aid  dressing  in  military  practice  (see  pp.  23 1-240). 
Immobilization  of  Injured  Joints  and  Fractured  Limbs. — 
In  the  case  of  fractures  and  joint  injuries,  the  affected  limb  should 
be  properly  immobilized  to  prevent  additional  injury  and  pain  dur- 
ing the  transportation  of  the  patient  to  the  field-hospital.  As  it  is 
impossible  for  the  surgeons  and  hospital  corps  to  carry  with  them 
upon  the  battle-field  material  for  splints  in  sufficient  quantity,  they 
must  depend  upon  articles  that  can  always  be  found  upon  the 
battle-field  in  securing  for  the  limb  a  proper  mechanical  support. 
A  few  of  such  extemporaneous  dressings  have  already  been  shown 
(see  Figs.  142-152). 

The  splint  should  be  well  padded  with  the  blanket  or  articles  of 
wearing  apparel.  In  compound  fractures  and  penetrating  wounds 
of  joints  perfect  immobilization  by  a  plaster-of- Paris  splint  should 
be  secured  as  soon  as  possible  ;  but  as  this  can  not  be  done  behind 
the  fighting-line,  for  obvious  reasons,  the  temporary  improvised 
dressing  should  be  replaced  by  the  permanent  fixation  dressing 
at  the  field-hospital.  Antiseptic  precautions  and  perfect  immo- 
bilization will  be  the  most  important  elements  in  the  conservative 
treatment  of  compound  fractures  and  penetrating  injuries  of  large 
joints. 

Transportation  of  Sick  and  Wounded. — Increased  and  im- 
proved facilities  for  rapid  transportation  of  the  wounded  from  the 
fighting-line  to  a  place  of  safety  will  be  an  essential  requirement  in 
securing  the  greatest  amount  of  benefit  from  conservative  surgery 
upon  future  battle-fields.  The  general  introduction  of  the  new  in- 
fantry weapon  will  make  it  necessary  to  establish  the  field-ho.spital 
further  away  from  the  fighting-line  than  it  was  formerly.  Unless 
a  natural  protection  by  a  hill  or  deep  ravine  is  available,  it  will  be 
necessary  to  locate  the  field-hospital  at  least  3000  meters  from  the 
line  of  action.  This  will  necessitate  an  improved  ambulance  ser- 
vice. The  latter  will  be  resorted  to  in  transporting  the  severely 
wounded  from  the  point  where  the  first  aid  is  rendered  to  the  first 
dre.ssing  station. 

A  well -trained  hospital  corps  and  the  use  of  improved  litters 
and  ambulances  will  be  instrumental  in  securing  prompt  and  easy 


2  54  GUNSHOT    WOUNDS. 

conveyance  of  the  wounded  from  the  Hne  of  duty  to  their  destina- 
tion. An  efficient  bicycle  Htter  is  a  much-needed  desideratum  in 
the  transportation  of  the  wounded  from  the  fighting-hne  to  the  first 
dressing  station  and  field-hospital. 

The  Surgeon's  Work  at  the  Field-hospital. — The  conserva- 
tive work  begun  on  the  battle-field  is  continued  at  the  field-hospital, 
which  offers  additional  facilities  for  the  practice  of  ideal  conserva- 
tive surgery.  It  is  here  that  efficient  measures  can  be  employed  to 
correct  the  injurious  effects  of  profuse  hemorrhage  and  to  overcome 
the  symptoms  of  prolonged  shock.  It  is  here  that  every  serious 
wound  will  be  thoroughly  examined,  and  under  strict  antiseptic 
precautions  will  be  subjected  to  the  necessary  treatment.  It  is  here 
where  permanent  hemostasis  will  be  substituted  for  temporary 
measures.  It  is  here  that  the  abdomen  and  cranial  cavities  will  be 
opened  for  penetrating  wounds  requiring  such  intervention  for  the 
arrest  of  hemorrhage,  the  removal  of  foreign  infected  bodies,  and 
the  direct  treatment  of  visceral  wounds.  It  is  here  that  permanent 
plaster-of- Paris  splints  will  be  substituted  for  the  temporary  fixation 
dressings  in  cases  of  compound  fractures  and  penetrating  wounds 
of  joints. 

Craniectomy. — Operative  interference  is  indicated  in  every  case 
of  penetrating  gunshot  or  stab  wound  of  the  cranmm.  The  object 
of  such  operation  is  to  secure  asepticity  of  the  wound  and  its 
environment,  the  removal  of  loose  spiculae  of  bone  and  infected 
foreign  substances,  the  arrest  of  hemorrhage  by  torsion,  ligation, 
or  tamponade,  and,  if  feasible,  the  removal  of  the  bullet. 

The  wound  of  entrance  is  sufficiently  enlarged  with  chisel  or 
rongeur  forceps  to  enable  the  surgeon  to  meet  the  indications  for 
the  operation.  If  the  bullet  is  lodged  in  the  interior  of  the  skull, 
it  may  become  necessary  to  make  a  circular  craniectomy  in  the 
course  of  the  bullet  at  a  point  opposite  the  wound  of  entrance,  for 
the  purpose  of  establishing  thorough  drainage  and  to  facilitate  the 
removal  of  the  bullet. 

Laparotomy. — The  sanguine  expectations  as  to  the  benefits 
to  be  derived  from  laparotomy  on  the  battle-field  have  not  been 
realized  after  ample  experience.  The  only  place  where  such  an 
operation  in  well-selected  cases  is  advisable  and  expedient  is  in  the 
field-hospital. 

Amputation. — The  object  of  conservative  surgery  upon  the 
battle-field,  as  well  as  in  civil  practice,  is  to  obviate,  whenever  pos- 
sible, the  necessity  of  mutilating  operations.  Prompt  and  careful 
hemostasis,  antiseptic  precautions,  immobilization  of  compound 
fractures  and  injured  joints,  and  early  and  careful  transportation  of 
the  wounded  from  the  field-hospital  to  the  temporary  hospital  are 
the  most  fruitful  resources  of  the  modern  military  surgeon  in  the 
prevention  of  complications  that  so  often  necessitated  intermediate 
and  secondary  amputations  in  the  wars  of  the  past.  A  primary 
amputation  for  gunshot  wound  of  the  extremities  is  only  justifiable 


GUNSHOT    WOUNDS    OF    THE    SKULL.  255 

by  extensive  injuries  of  soft  parts  and  fractures  and  joint  wounds 
complicated  by  injury  of  large  vessels  and  nerves.  In  other  words, 
the  indications  for  a  primary  amputation  will  be  studied  and  sought 
for  more  by  the  character  and  extent  of  the  injury  of  the  soft  tis- 
sues than  the  extent  of  the  bone-  or  joint-lesion.  In  doubtful  cases 
the  patient  will  be  given  the  benefit  of  the  doubt,  as  under  antisep- 
tic precautions  the  risk  to  life  is  greatly  diminished  in  the  attempt 
to  save  a  limb  by  conservative  treatment.  The  conditions  that  will 
demand  an  intermediate  or  secondary  amputation  in  cases  thus 
treated  will  prove  less  perilous  to  life  than  in  the  past,  an  additional 
inducement  to  practise  conservatism  in  doubtful  cases. 

Resection. — Primary  resection  for  gunshot  wounds  of  joints 
has,  for  obvious  reasons,  become  an  obsolete  operation  in  modern 
military  surgery.  The  most  brilliant  results  have  already  been 
obtained  by  conservative  treatment  of  such  cases.  The  military 
surgeon  will  make  it  his  duty  in  such  instances  to  resort  to  such 
measures  as  will  prevent  complications  necessitating  secondary 
resection  and  amputation.  Thorough  disinfection  of  the  wound, 
removal  of  loose  fragments  of  bone  and  infected  foreign  substances, 
including  the  extraction  of  the  bullet,  if  this  is  found  within  or  in 
the  immediate  vicinity  of  the  injured  joint,  gauze  drainage,  and 
immobilization  of  the  limb  in  a  circular  plaster-of- Paris  splint  are 
the  most  effective  measures  in  accomplishing  this  end. 

I  have  briefly  sketched  in  this  section  the  essential  topics  that 
will  engage  the  attention  of  the  military  surgeon  in  the  future  in 
keeping  pace  with  the  rapid  advances  of  modern  surgery,  and  that 
will  enable  him  to  extend  the  blessings  of  conservative  surgery  to 
the  wounded  soldier  on  the  battle-field  of  the  future.  It  behooves 
every  military  surgeon  to  perfect  himself  in  the  principles  and 
details  upon  which  his  actions  are  based  in  the  practice  of  legiti- 
mate conservatism. 

GUNSHOT  WOUNDS  OF  THE  SKULL. 

It  is  my  purpose  to  limit  my  remarks  under  this  heading  to 
penetrating  gunshot  wounds  of  the  skull.  The  few  cases  of  this 
class  of  injuries  that  will  come  under  the  observation  of  the  mili- 
tary surgeon  will  invariably  require  operative  interference,  pro- 
vided it  holds  out  any  encouragement  whatever  of  saving  life. 
Gunshot  wounds  of  the  skull  at  close  range  are  hopeless  cases  from 
the  beginning,  because  the  explosive  effect  of  the  bullet  is  such 
that  death  results  in  from  a  few  minutes  to  a  (cw  hours  after  the 
injury,  the  skull  being  extensively  comminuted  and  fissured  and  its 
contents  greatly  contused. 

Von  Hcrgmann  saw  a  case  in  which  the  skull  was  broken  into 
ninety  fragments  (Mg.  153).  According  to  Pirogoff  and  Velpeau, 
isolated  gunshot  fractures  of  either  the  external  or  the  internal 
table  are  very  rare.  Von  Bergmann  has  described  a  case  of  frac- 
ture of  .the  internal  table  resulting  from  a  tangent  bullet  (Fig.  1 54). 


256 


GUNSHOT    WOUNDS. 


Wounds  of  the  skull  inflicted  in  the  nonexplosive  range  not 
infrequently  call  for  operative  treatment,  and  in  a  fair  percentage 
of  cases  the  result  is  favorable.  I  will  give  a  few  of  my  observa- 
tions in  Greece,  Turkey,  and  Cuba  illustrative  of  the  fact  that  pene- 
trating gunshot  wounds  of  the  skull  are  by  no  means  always  fatal, 
and  that  they  do  not  constitute  injuries  incompatible  with  full 
recovery  of  the  cerebral  functions. 

During  the  Greco -Turkish  war  I  saw  and  examined  the  follow- 
ing case  in  Athens  : 

Case  i. — Gunshot  Wound  of  Skull. — The  bullet  entered  above  the  orbit,  and  passed 
out  of  the  skull  in  the  parietal  region  on  the  same  side.  No  operative  treatment.  Heal- 
ing of  the  wounds  of  en- 
trance and  exit  by  pri- 
mary intention.  No  focal 
symptoms  at  any  time. 
Patient  became  fully  con- 
valescent. 

In  Turkey, 
during  the  same 
war,  I  had  an  op- 
portunity of  exam- 
ining a  number  of 
gunshot  wounds  of 
the  skull  involving 
its  contents  and 
that  recovered  with 
and  without  surg- 
ical interference. 

Case  2. — Bullet 
Wound  of  Ordit.—BsiU 
entered  over  right  su- 
perciliary ridge,  passed 
backward,  outward,  and 
downward,  escaping  be- 
low and  in  front  of  the 
external  ear  on  the  same 
side.  Wound  healed  and 
patient  wears  an  artificial 
eye  with  comfort. 

Case  3. — Retrobulbar  Gunshot  Wound  of  Right  Eye. — Bullet  entered  orbit,  passed 
behind  the  eyeball,  and  escaped  in  front  of  the  external  meatus  on  the  same  side.  Trau- 
matic optic  neuritis  destroyed  the  eyesight  completely.  Patient  refused  enucleation. 
There  were  no  sympathetic  complications. 

Case  4. —  Gunshot  Injury  of  Skull. — Primary  operation.  Removal  of  depressed  frag- 
ments of  bone.     Wound  healed,  leaving  a  pulsating  cranial  defect. 

Case  5. — Penetrating  Gunshot  Wound  of  Skull. — Removal  of  loose  fragments  of 
bone.  No  focal  symptoms.  Wound  healed,  leaving  a  pulsating  scar.  Bullet  remained 
in  the  interior  of  the  skull.      No  mental  symptoms. 

Trephining  for  Traumatic  Abscess  of  the  Brain. — Djemil 
Pasha,  of  the  Yildig  Hospital,  informed  me  that  trephining  for 
abscess  of  the  brain  following  gunshot  injuries,  with  lodgment  of 
the  bullet  in  the  cranial  cavity,  was  performed  three  times  in  the 
military  hospitals  of  Turkey  during  the  late  war  with  Greece.      In 


Fig.  153. — Extensively  comminuted  gunshot  fracture  of  the 
skull  (after  von  Bergmann). 


GUNSHOT    WOUNDS    OF    THE    SKULL. 


257 


Fig.  154. — Gunshot  fracture  of  internal  table 
of  the  skull  (after  von  Bergmann). 


all  the  cases  the  indications  for  the  operation  were  furnished  by  the 

intracranial  suppuration.      In  every  case  the  abscess  was  found  and 

the  bullet   removed.     Two   of 

the    cases    recovered   and   one 

died.      To  my  own  knowledge 

a  number  of  gunshot  wounds 

of  the  skull  that  survived  long 

enough   to   be    transported   to 

the  General  Hospital  at  Siboney 

during   the   Spanish-American 

war   died    within   twelve   days 

after  the  receipt  of  the  injury. 

In    all    the    cases    intracranial 

infection    was    the    immediate 

cause  of   death.      Encephalitis 

and  leptomeningitis  constituted 

the   fatal    complications.      The 

beginning    of  the    intracranial 

inflammation  was  always  an- 
nounced   by    cerebral    hernia, 

which  was  proportionate  in  size 

to  the  extent  and  intensity  of 

the  inflammation.  The  surg- 
ical  treatment  resorted    to    in 

most  instances  proved  powerless  in  limiting  the  infection.      If  these 

cases  had  been  studied  with  a  little  more  care  during  life,  and  if 

postmortem  examinations 
had  been  made  more  fre- 
quently, valuable  material 
could  have  been  obtained 
for  the  advancement  for 
the  as  yet  imperfectly  de- 
veloped science  of  cere- 
bral localization.  The  fol- 
lowing cases  merit  atten- 
tion here  : 

Case  6.  —  P'red  Shockley, 
Company  D,  Tenth  Cavalry, 
wounded  July  2d.  When  injury 
was  received  patient  was  lying  on 
his  abdomen  at  the  base  of  the 
ridge  occu|)ied  t)y  the  eiicniy,  with 
the  head  and  chest  extended,  fac- 
ing tiie  Spanish  line.  This  |)osi- 
tion  readily  explains  the  unusual 
course  of  the  bullet,  which  struck 
the  occi|)ital  base  at  a  tangent, 
|)roducing  a  conuniniited  fracture 
with  depression  ;  it  ti)en  made  a 
deep  groove  in  the  back  of  the  neck,  and  reentered  the  body  on  a  level  with  the  first  rib, 
to  the  level  of  the  third  dorsal  vertebra ;  it  then  passed  through  the  chest,  and  escaped 

17 


f^'K-    155- — Gunshot  wound  of  skull,   neck,   and 
cliest. 


258 


GUNSHOT    WOUNDS. 


in  front  through  the  second  intercostal  space,  a  little  to  the  left  of  the  mammary  line 
(Fig.  155).  Soon  after  the  injury  was  received  he  coughed  up  a  small  quantity  of  blood  ; 
there  was  no  hemorrhage  following  this,  nor  were  there  any  indications  of  pneumothorax, 
pneumonia,  or  pleuritis.  The  chest  wounds  healed  by  primary  intention.  At  first  he  had 
convulsions  for  a  few  moments  ;  no  loss  of  consciousness,  but  clonic  spasms  of  both  arms. 
Intellect  remained  unimpaired  ;  he  had  some  headache,  and  a  sensation  of  throbbing  in 
the  head,  and  there  was  some  impairment  of  motion  and  sensation  of  the  right  leg,  and 
complete  loss  of  motion  of  the  toes  of  the  right  foot ;  there  was  some  pain  in  the  eyes 
and  slight  dimness  of  vision. 

Case  7. — Patrick  Ward,  Company  I,  Third  Cavalry,  admitted  from  hospital  at 
Siboney  to  the  hospital  ship  Relief  July  iith.  Injury  received  probably  in  the  same 
manner  as  in  the  preceding  case.  A  large  defect  in  the  occipital  bone  marked  the 
wounds  of  entrance  and  exit  in  the  skull  ;  the  openings  were  enlarged  by  operation. 
The  linear  wound  below,  and  extending  as  far  as  the  last  cervical  vertebra,  was  un- 
doubtedly made  in  following  and  removing  the  bullet.  The  cranial  defect  and  the  course 
of  the  bullet  are  outlined  in  figure  156.  A  cerebral  hernia  projected  from  the  opening, 
and  a  deep-seated  cerebral  abscess  was  recently  discovered,  opened,  and  drained.  In 
part  the  hernia  was  covered  by  skin.  Both  parietal  bones  were  the  seat  of  a  comminuted 
fracture.  Mental  faculties  were  not  impaired,  and  there  were  no  focal  symptoms.  The 
patient  lost  strength  rapidly,  and  soon  succumbed  to  the  intracranial  disease. 

Case  8. — Jerome  Russell,  Company  A,  Thirteenth  Infantry,  was  wounded  July  1st. 
When  brought  on  board  the  Relief,  July  nth,  a  cerebral  hernia  of  the  size  of  a  hen's 


Fig.  156. — Gunshot  fracture  of  the  skull. 


Fig. 


157. — Gunshot    fracture 
of  the  skull. 


egg  was  found  over  the  sagittal  suture,  an  inch  in  front  of  the  occipital  protuberance. 
The  wound  was  suppurating,  and  digital  exploration  revealed  a  small  circular  defect 
directly  in  front  of  the  occipital  protuberance.  This  opening  was  evidently  the  wound 
of  entrance,  and  by  operation  had  been  connected  with  the  wound  of  exit  by  a  channel 
an  inch  in  length  and  half  an  inch  wide.  The  hernia  corresponded  with  the  location  of 
the  wound  of  exit.  A  number  of  loose  fragments  of  bone  were  removed  at  different 
times.  There  was  marked  hemiplegia  on  the  left  side,  and  the  forearm  was  strongly 
flexed  and  in  close  contact  with  the  chest.  Sensation  was  not  impaired ;  speech  was 
clear,  but  ideas  were  confused  ;  pupils  reacted  to  light ;  there  was  incontinence  of 
urine,  and  extensive  decubitus  over  sacrum;  temperature  was  100.5°  F.  ;  pulse  and 
respiration  were  normal.      Death  occurred  a  few  days  later  from  sepsis. 

Case  9. — B.  C.  Parker,  Company  C,  Fourth  Infantry,  was  wounded  July  1st.  The 
bullet  entered  the  left  temporal  region,  comminuting  the  bone  in  that  location  extensively, 
and  escaped  over  the  left  frontal  eminence  (Fig.  157).  The  cranial  defect  was  increased 
by  the  removal  of  a  number  of  loose  fragments.  There  was  quite  a  profuse  seropurulent 
discharge  from  the  wound.  The  only  focal  symptom  consisted  of  a  pricking  sensation  in 
the  right  foot  or  chest  when  the  wound  was  being  dressed.  His  mind  was  clear  most  of 
the  time  ;  occasionally  there  were  slight  confusion  and  wandering.  The  absence  of  cere- 
bral hernia  in  this  case  is  the  surest  indication  that  the  infection  was  local. 

The  foregoing  cases  furnish  sufficient  proof  of  the  facts  that 
the  remote  cause  of  death  in  penetrating  wounds  of  the  skull  is 


GUNSHOT    WOUxNDS    OF    THE    NECK.  259 

almost  always  an  intracranial  infection,  and  that  early  operative  in- 
terference is  the  best  means  to  prevent  such  a  complication. 

Treatment. — In  case  a  bullet  has  passed  through  the  skull  and 
its  contents,  the  entire  scalp  should  be  shaved  and  thoroughly 
disinfected.  The  wound  of  entrance  must  be  enlarged  sufficiently 
to  expose  the  perforation  freely,  which  is  then  increased  in  size  to 
the  required  extent  with  chisel,  De  Vilbiss,  or  rongeur  forceps,  to 
enable  the  surgeon  to  remove  the  loose  spiculae  of  bone  which  are 
frequently  found  driven  some  distance  into  the  substance  of  the  brain. 
With  a  long-eyed  probe  a  strip  of  iodoform  gauze,  large  enough 
to  pack  loosely  the  tubular  visceral  wound,  should  be  inserted 
from  the  wound  of  entrance  to  the  wound  of  exit,  and  the  ends  of 
the  gauze  drain  made  to  project  a  few  inches  beyond  the  surface  of 
each  wound.  Efficient  capillary  drainage  of  this  kind  will  pre\'ent 
accumulation  of  primary'  wound  secretion  in  the  interior  of  the 
skull,  and  will  prove  useful  in  arresting  capillary  hemorrhage.  A 
large  hygroscopic  aseptic  dressing  enveloping  the  entire  scalp  and 
covering  both  wounds  constitutes  the  dressing,  and  must  be  held  in 
place  by  a  few  turns  of  a  plaster-of- Paris  bandage.  The  drain  must 
be  allowed  to  remain  until  the  danger  of  infection  is  past,  when  it 
is  to  be  removed  gradually  by  shortening  it  eveiy  day  or  two  on 
the  side  of  the  wound  of  entrance. 

In  case  the  bullet  should  be  found  lodged  in  the  interior  of  the 
skull,  the  wound  of  entrance  must  be  treated  in  the  same  manner 
and  the  bullet  located  by  the  careful  use  of  Fluhrer's  aluminum 
probe,  the  X-ray,  or  by  a  combination  of  these  two  diagnostic 
resources.  A  counteropening  may  become  necessary  in  removing 
the  bullet  if  it  has  reached  the  opposite  side  of  the  cranial  cavity,  or 
if  it  has  become  deflected  or  arrested  in  its  course  near  the  surface 
of  the  brain,  provided  the  locality  in  which  it  has  become  lodged 
warrants  operative  intervention.  In  all  visceral  lesions  of  the  con- 
tents of  the  skull  resulting  from  gunshot  injuries  capillary  or  tubu- 
lar drainage,  or  a  combination  of  the  two,  is  indicated  and  should 
be  continued  until  there  is  no  further  danger  of  infection,  hemor- 
rhage, or  accumulation  of  wound  secretions,  when  the  drain  is  to 
be  gradually  removed.  The  value  of  the  Rontgen  ray  in  locating 
bullets  in  the  interior  of  the  cranium  has  as  yet  not  been  definitely 
determined. 

GUNSHOT  WOUNDS  OF  THE  NECK. 

Some  very  remarkable  recoveries  following  grave  bullet  injuries 
of  the  neck  were  observed  in  Cuba,  of  which  the  following  furnish 
excellent  illustrations  : 

Cask  i. — Lieutenant  Albert  Scott,  Company  C,  Thirteenth  Infantry,  on  July  1st, 
while  standing  with  his  company  at  the  foot  of  a  hill,  during  the  advance  <>n  the  .Spanish 
breastworks,  received  a  wound  in  the  neck.  The  bullet  entered  on  the  rif^lit  side,  just 
below  the  inferior  maxillary  bone,  one  inch  in  front  of  theanfjjeof  the  jaw.  The  wound  of 
entrance  was  a  clear-cut  hole  ab<*ut  the  diameter  of  an  ordinary  lead-pencil.  The  course 
of  the  bullet  was  backward  and  slightly  downward,  emerging  at  the  back  of  the  neck  on 


26o 


GUNSHOT    WOUNDS. 


a  level  with  and  to  the  left  of  the  fifth  cervical  vertebra  (Fig.  158).  At  the  moment  the 
injury  was  inflicted  he  felt  no  pain  in  the  wound,  but  he  experienced  a  sensation  as  if  he 
had  been  grasped  by  the  wrists  and  thrown  violently  to  the  ground.  The  wound  of  exit 
was  of  the  same  size  and  appearance  as  the  wound  of  entrance.  There  was  very  slight 
hemorrhage.  A  few  minutes  after  he  was  shot  he  was  carried  from  the  firing-line  by 
members  of  his  company,  and  soon  reached  the  First  Division  Hospital,  where  he  re- 
mained for  ten  days.  At  the  end  of  this  time  he  was  removed  in  an  ambulance  to  the 
General  Hospital  at  Siboney,  a  distance  of  seven  miles,  over  a  very  rough  road,  and  a 
day  later  was  transferred  to  the  Relief.  He  first  became  aware  of  the  existence  and 
location  of  the  wound  on  the  way  from  the  field  to  the  hospital.  At  the  time  he  came 
on  board  the  hospital  ship  he  was  voiceless,  and  made  constant  efforts  to  clear  the  bron- 
chial tubes  of  mucus.  There  were  complete  paralysis  of  right  arm  and  leg  and  partial 
loss  of  power  in  left  arm  and  leg.  Respiration  was  normal,  but  an  almost  constant  spas- 
modic cough  was  present ;  he  had  no  control  over  sphincters,  and  there  were  involuntary 
passages  from  bladder  and  bowels,  and  great  debility  and  profuse  sweating.  He  com- 
plained of  pain  all  over  the  body.  Morphin  and  atropin  were  given  to  subdue  pain.  A 
radiograph  showed  an  injury  of  one  of  the  cervical  vertebrae,  probably  the  fifth.  Besides 
the  first-aid  dressing,  he  received  no  treatment  other  than  complete  rest  and  the  anodyne 
at  bedtime,  which  secured  a  good  night's  sleep  and  markedly  diminished  the  sweating. 
He  regained  control  of  the  sphincters  and  is  now  able  to  use  bed-pan  and  urinal. 

July  igth. — During  the  past  six  days  there  has  been  a  decided  improvement  in  the 
general  condition  of  the  patient.     He  is  brighter  in  appearance,  his  speech  is  returning^ 


Fig.  158. — Gunshot  wound 
of  the  neck. 


Gunshot  wound  of  the  neck. 


and  there  is  a  decided  improvement  of  motion  in  the  right  leg.  The  right  hand  is  still 
paralyzed,  but  the  grip  of  the  left  hand  is  decidedly  stronger.  General  condition  is 
improving  rapidly. 

July  2 1  St. — Improvement  in  general  condition  continues.  The  external  wounds 
healed  by  primary  intention,  and  the  scars  are  so  small  that  they  can  only  be  seen  on 
making  a  very  careful  inspection. 

The  patient  was  under  the  direct  care  of  contract  surgeon  Met- 
calfe, who  prepared  the  preceding  chnical  history. 

The  existence  of  a  fracture  of  one  of  the  cervical  vertebrae  was 
indicated  by  the  clinical  symptoms  and  confirmed  by  the  X-ray. 
The  concussion  of  the  spinal  cord  and  possibly  hemorrhage  into  the 
spinal  canal  were  the  probable  causes  of  the  diffuse  paralysis,  but 
the  persistence  of  the  paralysis  on  the  left  side  suggests  an  injury 
of  the  cervical  plexus  on  that  side,  and  may  result  in  permanent 
loss  of  function  in  the  territory  supplied  by  the  injured  nerve. 

Case  2. — Oscar  C.  Buck,  Company  F,  Second  Infantry,  was  shot  July  nth  by  a 
sharpshooter  hiding  in  a  tree.  The  bullet  passed  through  the  neck  from  side  to  side. 
The  first  and  only  evidence  the  patient  had  that  he  was  wounded  was  bleeding  from  the 


GUNSHOT    WOUNDS    OF    THE    CHEST.  26 1 

throat,  the  hemorrhage  at  first  being  quite  profuse.  Stiffness  of  the  neck  and  pain  on 
movement  were  the  only  symptoms  complained  of.  The  bullet  entered  over  the  sterno- 
cleidomastoid muscle  on  the  left  side,  about  two  inches  and  a  half  from  the  mastoid 
process.  The  wound  of  entrance  was  circular  and  very  small  ;  the  wound  of  exit  was 
on  the  same  level,  but  about  half  an  inch  nearer  the  spine  (Fig.  159J.  Three  days  later 
a  small  superfcial  abscess  formed  in  the  wound  of  exit,  which  was  evacuated  by  dilating 
the  wound.      Both  wounds  were  perfectly  healed  by  July  20th. 

Judging  from  the  course  of  the  bullet,  it  is  difficult  to  comprehend  how  the  principal 
nerves  and  large  vessels  of  the  neck  escaped  injury.  This  is,  however,  one  of  those  cases 
that  require  careful  watching,  as  a  traumatic  aneurysm  may  develop  later  in  the  track  of 
the  bullet,  which  may  have  injured  the  external  tunics  of  either  of  the  carotid  arteries. 

C.\SE  3. — Charles  F.  Flickinger,  Company  C,  Fourth  Infantry,  was  wounded  July 
1st,  while  lying  down.  The  bullet  entered  the  left  posterior  cervical  triangle,  on  a  level 
with  the  spinous  process  of  the  fifth  cervical  vertebra,  midway  between  the  spine  and  the 
posterior  border  of  the  sternocleidomastoid  muscle,  and  emerged  opposite  the  spinous 
process  of  the  seventh  dorsal  vertebra,  equidistant  from  that  point  and  the  posterior 
border  of  the  scapula.  The  patient  complained  of  severe  pain  in  the  shoulders  on  attempts 
to  move,  but  was  free  from  any  symptoms  that  would  have  indicated  any  injury  to  the 
spinal  column  or  its  contents.  He  was  within  loo  yards  of  the  enemy  when  he  was 
wounded. 

I  saw  the  following  two  cases  in  Athens  during  the  Greco-Turk- 
ish war  : 

Case  4. — Greek  soldier.  Bullet  wound  of  base  of  neck.  The  bullet  passed  trans- 
versely through  the  soft  tissues  of  the  neck,  behind  the  spinal  column,  and  probably 
caused  fracture  of  one  or  more  of  the  spinous  processes.  The  special  symptoms,  due  to 
concussion  which  followed  the  injury,  disappeared.  Healing  of  the  entire  wound  occurred 
without  suppuration. 

Case  5. — Gunshot  Wound  of  the  Clavicle  and  Scapula. — Clavicle  united  by  a  mas- 
sive callus.  Bullet  passed  from  before  backward,  above  the  large  vessels  and  nerves. 
Motion  of  arm  was  greatly  impaired. 

The  two  great  dangers  in  gunshot  wounds  of  the  neck  consist 
in  complicating  wounds  of  the  large  vessels  and  the  spinal  cord. 
Gunshot  injuries  of  any  of  the  carotid  arteries  involving  all  the 
tunics  result,  with  few  exceptions,  in  death  from  hemorrhage  on  the 
field.  Injury  of  any  extent  to  the  cervical  portion  of  the  cord,  as  a 
rule,  proves  fatal  in  a  short  time,  either  from  a  rapidly  spreading 
leptomeningitis  or  later  from  decubitus,  sepsis,  or  an  ascending  sep- 
tic inflammation  of  the  bladder,  ureters,  and  kidneys.  Wounds  of 
the  trachea  or  larynx  may  necessitate  a  tracheotomy.  If  the  spine 
is  fractured,  immobilization  becomes  an  important  part  of  the  treat- 
ment. Operative  treatment  in  such  cases  may  become  necessary 
if  the  nature  of  the  wound,  the  direction  of  the  bullet,  and  the  focal 
symptoms  point  to  the  presence  of  the  bullet  or  fragments  as  the 
cause  of  compression. 

GUNSHOT  WOUNDS  OF  THE  CHEST. 

Gunshot  injuries  of  the  chest  have  always  figured  conspicuously 
as  immediate  causes  of  death  on  the  battle-field  and  will  always 
do  so.  Wounds  of  the  heart  and  large  vessels  of  the  chest  will 
never  come  within  the  range  of  successful  surgery.  Penetrating 
gunshot  wounds  of  the  chest  are  attended  by  a  frightful  mortality, 
owing  to  the  physiologic  importance  of  the  organs  contained  in  the 
chest  cavity.  Visceral  injuries  of  the  heart  and  large  blood-vessels 
usually   result    in    death    in    a   few   moments    from   acute    anemia. 


262  GUNSHOT    WOUNDS. 

Hemorrhage  into  the  pleural  cavity  and  into  the  large  bronchial 
tubes  interferes  mechanically  with  the  respiratory  functions,  and 
frequently  proves  fatal  in  a  short  time.  If  the  wounded  do  recover 
from  its  immediate  effects,  life  is  placed  in  danger  by  subsequent 
complications,  which  are  so  often  caused  by  the  hemothorax. 
However,  the  accumulation  of  even  a  large  quantity  of  blood  in 
the  pleural  cavity  is  not  incompatible  with  a  satisfactory  recovery 
without  operative  interference,  for  when  the  blood  is  aseptic  and 
remains  so,  its  removal  by  absorption  is  accomplished  in  the  course 
of  time. 

In  gunshot  wounds  of  the  heart  death  is  caused  by  heart  com- 
pression on  the  part  of  the  blood  that  accumulates  in  the  pericar- 
dium— the  pericardial  tamponade  of  E.  Rose.  I  shot  a  deer  at 
close  range  with  buckshot,  aiming  at  the  heart.  The  animal  ran 
more  than  200  yards,  and  Avas  found  lying  dead  in  the  brush. 
Postmortem  revealed  four  wounds  involving  the  large  blood-vessels 
and  the  base  of  the  heart,  and  the  pericardium  was  distended  to  its 
utmost  capacity  by  fluid  blood.  Experience  during  the  Civil  War 
proved  that  in  gunshot  wounds  of  the  chest  the  chances  for  life 
were  much  better  if  the  bullet  passed  through  the  chest  than  if 
it  remained  lodged  in  the  body,  an  experience  fully  corroborated 
during  the  Spanish-American  war.  I  saw  a  number  of  soldiers 
of  the  Greco-Turkish  war,  who  had  been  shot  through  the  chest, 
convalescent  and  in  fair  health  a  few  weeks  after  the  injury  was 
received. 

The  following  cases  from  this  source  are  of  sufficient  interest  to 
be  mentioned  in  brief : 

Case  i. — Greek  soldier,  the  subject  of  bullet  wounds  of  the  chest.  Three  wounds 
of  entrance  over  the  anterior  and  upper  aspect  of  the  chest.  One  of  the  bullets  passed 
through  the  chest  on  the  left  side  of  the  sternum  ;  the  point  of  exit  was  over  the  scapula 
on  the  same  side.  The  other  two  wounds  were  inflicted  by  the  contents  of  a  bursting 
shell.  The  size  of  the  scars  indicated  that  the  missiles  were  less  than  38  caliber  in  size. 
No  attempt  was  made  to  locate  the  two  projectiles  lodged  somewhere  in  the  chest. 
There  was  free  hemoptysis  immediately  after  the  injury.  The  patient  recovered  without 
any  grave  complications  setting  in. 

Case  2.  —  Gunshot  Wotmd  of  Chest  with  Fracture  of  Spinous  Processes  of  One  or 
More  of  the  Dorsal  Vertebrce. — Track  made  by  the  bullet  transverse  at  about  the  junc- 
tion of  the  upper  with  the  middle  third  of  the  dorsal  spine.  The  pleural  cavity  was 
not  opened.  The  wound  of  entrance  was  on  one  side  of  the  spine  ;  incision  was  made 
for  the  extraction  of  the  bullet  on  the  other  side  on  the  same  level.  Spinal  symptoms 
were  well  marked  immediately  after  the  injury  was  received,  but  they  disappeared 
rapidly.      Primary  healing  of  wounds  occurred. 

Case  3. — Penetrating  Gunshot  Wound  of  Chest. — There  was  only  a  wound  of 
entrance  ;  no  attempts  were  made  to  find  or  remove  the  bullet.  Injury  was  followed  by 
empyema.  Drainage  was  instituted  without  rib  resection.  The  injured  side  of  the  chest 
was  contracted,  and  respiratory  movements  were  greatly  diminished.  Patient  was  pale 
and  emaciated,  and  showed,  in  a  marked  manner,  the  effects  of  prolonged  suppura- 
tion. 

Case  4.  —  Gunshot  Wound  of  Chest  and  Abdomen. — Bullet  entered  dorsal  side  of 
chest  on  a  level  with  the  eighth  rib,  four  inches  from  the  median  line,  took  a  downward 
and  forward  course,  and  escaped  an  inch  below  the  costal  arch  on  the  same  side,  at  a 
point  corresponding  to  the  cartilage  of  the  seventh  rib.  No  operation  performed.  Bile 
escaped  through  the  anterior  perforation  for  a  number  of  days.  Wounds  healed  by  pri- 
mary intention.  There  were  no  serious  inflammatory  complications.  Patient  became 
fully  convalescent. 


GUNSHOT  WOUNDS  OF  THE  CHEST. 


263 


The  following  cases  came   under  my  observation   during   my 
service  in  Cuba. 


Fig.  160. — Gunshot  wound  of  the  chest. 


Fig.  161. — Penetrating  wound  of  the 
chest. 


Fig.  162. — Gunshot  wound  of  chest,  neck,       Fig.  163. — Gunshot  wound  of  chest,  neck, 
and  mouth.  and  mouth. 


The  number  of  cases  of  penetrating  gunshot  wounds  of  the 


264 


GUNSHOT    WOUNDS. 


chest  that  Hved  long  enough  to  reach  the  General  Hospital  at 
Siboney  exceeded  our  expectations,  and  what  was  still  more  sur- 
prising was  the  fact  that  unless  the  hemorrhage  into  the  cavity  of 
the  chest  was  copious,  the  symptoms  were  mild,  some  of  the 
patients  being  confined  to  bed  for  a  few  days  only.  All  these 
cases  were  treated  on  the  expectant  plan— z.  e.,  by  dressing  the 
external  wound  or  wounds  in  the  usual  manner,  by  applying  the 
first-aid  dressing.  In  no  instance  was  the  pleural  cavity  opened 
for  the  purpose  of  arresting  the  hemorrhage. 


Case  5. — Wm.  A.  Cooper,  Company  A,  Tenth  Cavalry,  was  wounded  July  1st. 
The  bullet  entered  an  inch  below  the  left  nipple,  and  escaped  from  the  body  an  inch 
below  the  costal  arch,  in  the  mammary  line  (Fig.  160).  It  is  questionable  whether  the 
bullet  opened  either  the  pleural  or  peritoneal  cavity,  as  the  injury  was  not  followed  by 
any  symptoms  referable  to  visceral  wounds  of  the  chest  or  abdomen,  although  the  course 
of  the  bullet  was  such  that  we  had  reason  to  assume  that  both  of  these  cavities  had  been 
invaded. 

Case  6. — Edward  O' Flaherty,  Company  C,  Sixteenth  Infantry,  was  wounded  July 
2d  by  a  45-caliber  ball  from  a  bursting  shrapnel.  The  projectile  entered  below  the  angle 
of  the  right  scapula,  passed  through  the  lung,  diaphragm,  and  liver,  lodging  beneath  the 

skin  in  front,  between  the  seventh 
and  eighth  ribs.  Bloody  expec- 
toration followed  for  some  time, 
and  there  was  slight  rise  in  tem- 
perature. 

July  i2lh.  —  Temperature 
normal. 

Jtdy  2 1st. — Patient  suffers 
but  little  inconvenience  from  his 
wound.  No  peritoneal  or  pleural 
effusion.  General  condition  prom- 
ises an  early  and  complete  recov- 
ery. 

Case  7. — John  B.  Senica, 
Company  G,  Twenty-second  In- 
fantry, was  wounded  July  1st  by 
a  bullet  that  entered  his  back, 
just  below  the  angle  of  the 
scapula,  passed  upward  through 
the  lung,  neck,  and  jaw,  and 
emerged  through  the  alveolar 
process  of  the  right  lower  tri- 
cuspid tooth,  cutting  the  tongue 
slightly,  and  escaped  through  the 
cheek  near  the  mouth  (Figs.  162 
and  163).  All  wounds  healed  in 
a  short  time  by  primary  intention. 
Hemoptysis  was  profuse  immediately  after  he  was  shot,  and  slight  for  the  following  few 
days.  The  left  arm  was  at  first  nearly  powerless,  with  desquamation  of  the  skin  of  the 
hand.  The  function  of  the  arm  returned  gradually.  In  three  weeks  the  patient  was  able 
to  sit  up  for  a  short  time  each  day.  Physical  examination  of  the  chest  at  this  time 
revealed  nothing  abnormal. 

Case  8. — Winslow  Clark,  Company  G,  First  Volunteer  Cavalry,  was  wounded  July 
1st  by  a  bullet  that  entered  the  chest  by  first  perforating  the  left  scapula  through  the 
infraspinous  fossa,  three  inches  above  the  angle  and  one  inch  from  the  spinal  border  (Fig. 
161).  There  was  no  wound  of  exit.  The  probable  course  of  the  bullet  was  downward 
and  forward.  Some  hemoptysis  and  fever  occurred,  but  no  vomiting  of  blood.  The 
hemothorax  was  quite  extensive,  and  was  relieved  by  aspiration  a  week  after  the  injury 
was  received.     At  the  end  of  the  third  week  he  appeared  to  be  convalescing  rapidly. 

Case  9. — Arthur  Fairbrother,  Company  C,  Third  Cavalry,  sustained  a  perforating 
gunshot  wound  of  the  chest  on  July  1st.  The  bullet  entered  the  chest  just  below  the 
middle  of  the  right  clavicle  (Fig.  164).     There  was  no  wound  of  exit.     Hemoptysis 


Fig.  164. — Penetrating  wound  of  the  chest. 


GUNSHOT    WOUNDS    OF    THE    CHEST. 


265 


was  quite  profuse,  followed  by  hemothorax.  He  had  occasional  attacks  of  fever,  prob- 
ably malarial. 

July  isth. — Patient  was  admitted  to  the  Relief.  Wound  not  completely  closed. 
On  coughing,  dark  fluid  blood  escapes.  The  entire  pleural  cavity  is  almost  filled  with 
blood. 

Two  days  later  three  pints  of  the  same  kind  of  blood  were  removed  by  tapping 
and  siphonage.      Sputum  at  this  time  is  still  bloody. 

July  23d. — Patient  much  improved.  No  signs  of  empyema.  Hemothorax  dimin- 
ished, but  may  require  a  second  tapping. 

Case  10. Scanlon,  Company  K,  Third  Cavalry,  was  wounded  on  the  second 

day  of  the  battle  of  Santiago.  The  ball  entered  the  chest  through  the  third  rib,  midcla- 
vicular line,  on  the  right  side,  passed  downward  and  backward,  and  escaped  in  the  gluteal 
region  on  the  same  side,  after  perforating  the  ilium  (Figs.  165,  166).  The  bullet  must 
have  passed  through  the  lung,  diaphragm,  and  liver.  Hemoptysis  slight,  but  there  were 
distressing  nausea,  vomiting,  and  pain.      He  was  admitted  to  the  hospital  ship  Relief 


Fig.  165. 


-Penetrating  wound  of  chest 
and  abdomen. 


Fig.  166. — Penetrating  wound  of  chest 
and  abdomen. 


July  15th.  At  that  time  he  had  a  constant  temperature  ranging  between  100°  and  102°  F., 
vomiting,  diarrhea,  and  rapid  pulse,  with  marked  progressive  emaciation.  There  was 
great  i)ain  over  the  liver  and  ascending  colon  ;  hemolliorax  and  marked  swelling  in  the 
region  of  the  liver  and  abdominal  cavity  on  the  right  side  were  present.  Examination 
of  urine  negative.  Owing  to  the  great  debility  and  pronounced  anemia  it  was  not  deemed 
advisable  to  re.sort  to  laparotomy,  and  the  patient  died  a  few  days  later  on  the  arrival 
of  the  ship  in  the  harbor  of  New  \'ork. 

Case  II. — Harry  Mitchell,  Company  C,  Seventh  Infantry,  was  wounded  July  1st. 
The  bullet  entered  over  the  right  acromion  ])rocess,  passed  through  the  a])iccs  of  both 
lungs,  aiifl  escaped  through  the  .second  intercostal  space  above  the  right  nipjile.  There 
was  no  hemoptysis  at  any  time.  Dry  cough  and  a  moderate  hemothorax  on  the  right 
side  were  present.  He  had  suffered  from  the  (|uotidian  form  of' malarial  fever,  which 
yielded  to  quinin.      A  speedy  and  complete  recovery  was  expected. 

Case  12. — Lieutenant  John  Robertson,  Company  (i,  Sixth  Infantry,  received  a  gun- 


266 


GUNSHOT    WOUNDS. 


shot  wound  of  the  upper  third  of  the  right  thigh  at  about  lo  o'clock  on  July  1st.  The 
profuse  hemorrhage  was  partly  controlled  by  an  improvised  tourniquet  applied  by  an 
officer  of  the  line.  He  was  conveyed  to  the  rear  by  the  men  of  his  own  company,  and 
while  thus  being  carried,  he  was  shot  in  the  left  breast,  the  bullet  entering  just  below 
the  left  nipple  and  passing  through  the  chest  in  an  anteroposterior  direction  (Fig.  167). 
Shortly  after,  he  was  wounded  a  third  time,  the  bullet  grazing  the  inner  side  of  the  left 
knee.      Two  of  the  men  who  assisted  him  were  killed  and  others  took  their  places. 

The  first  dressing  was  ap- 
plied at  the  First  Division  Hos- 
pital. The  fracture  of  the  thigh 
was  immobilized  by  a  long  splint. 
From  here  he  was  sent,  July  9th, 
to  the  General  Hospital  at  Sib- 
oney,  and  two  days  later  was 
transferred  to  the  Relief.  At 
this  time  both  chest  wounds  were 
healed.  The  thigh  wounds  re- 
mained aseptic.  The  X-ray  used 
at  this  time  showed  great  dis- 
placement of  the  fragments  by 
overlapping.  The  limb  was  now 
confined  upon  a  double  inclined 
plane,  consisting  of  a  hollow 
posterior  splint  made  of  the  sheath 
of  the  leaf  of  the  cocoanut  palm, 
to  which  was  added  an  anterior 
splint  of  wire  gauze.  The  limb, 
thus  immobilized,  was  suspended. 
No  pulmonary  or  pleuritic  com- 
plications ensued. 

Case  13.^ — Henry  T.  Darby, 

Company  D,  Thirteenth  Infantry, 

received    a    perforating   gunshot 

wound  of  the  chest  on  July  1st. 

The    ball    entered   on    the    right 

side,  above  the  angle  and  at  the  outer  border  of  the  right  scapula,  passed  through  the 

chest,  and  escaped  through  the  fourth  intercostal  space  in  front  on  the  opposite  side,  two 

inches  outside  the  mammary  line. 

When  the  patient  came  on  board  the  Relief,  July  9th,  he  complained  of  great  diffi- 
culty in  breathing  ;  he  was  pale  and  greatly  prostrated ;  temperature  reached  100°  F. 
The  physical  signs  indicated  the  presence  of  a  copious  pleuritic  effiision  on  the  left  side. 
The  chest  was  opened  by  an  incision  through  the  sixth  intercostal  space  in  the  axillary  line 
on  July  nth.  About  three  pints  of  fluid  blood  escaped.  Gauze  drainage  was  instituted. 
In  this  case  an  empyema  developed  after  a  few  days,  and  the  ultimate  result  is  unknown. 

No  further  doubt  can  remain  in  regard  to  the  difference  in  the 
mortahty  of  gunshot  wounds  of  the  chest  inflicted  with  the  large- 
and  small-cahber  bullet.  The  cases  just  related  appear  to  prove 
that  the  danger  incident  to  gunshot  wounds  of  the  chest  made  by 
the  small-caliber  projectile  consists  in  complicating  injuries  involv- 
ing the  heart  and  large  blood-vessels,  and  that  in  the  absence  of 
such  injuries  the  prognosis  is  quite  favorable.  In  cases  in  which  the 
penetrating  wound  was  not  complicated,  rapid  recovery  was  the 
rule. 

A  very  interesting  study  of  the  ultimate  results  of  penetrating 
gunshot  injuries  of  the  chest  from  the  Cuban  campaign  has  recently 
been  made  by  my  former  assistant  during  my  service,  now  First 
Lieutenant  Henry  S.  Greenleaf,  U.S.A.  The  paper  will  be  pub- 
lished elsewhere,  but  the  author  has  very  kindly  furnished  me  with 
a  copy,  which  I  am  glad  to  make  use  of  here.     A  number  of  the 


Fig.  167. — Penetrating  gunshot  wound  of  the  chest. 


GUNSHOT    WOUNDS    OF    THE    CHEST.  267 

wounded  previously  reported  again  figure  in  this  paper,  showing 
that  in  penetrating  gunshot  wounds  of  the  chest  attended  by  marked 
hemothorax  empyema  developed  more  frequently  than  we  expected, 
and  operative  treatment  in  such  cases  became  a  later  necessity. 

"  To  get  our  sick  and  wounded  into  well-established  hospitals 
for  their  ultimate  treatment,  and  away  from  the  dangers  of  contagion 
and  other  unhealthy  surroundings,  during  our  late  war  with  Spain 
required  frequent  transfers,  which  have  left  some  very  unsatisfac- 
tory and  unconnected  data  for  records,  and  might  readily  have  led  to 
erroneous  conclusions  regarding  prognosis  or  treatment  when  con- 
sidered under  the  conditions  of  war.  There  is  much  that  would  be 
instructive  and  valuable  to  know  if  we  could  connect  the  history  of 
these  cases  from  beginning  to  end,  as  they  progressed  in  the  differ- 
ent places  where  they  were  under  treatment. 

"  For  this  reason  it  is  my  belief  that  there  is  much  misappre- 
hension concerning  the  nature  of  many  of  the  gunshot  wounds  of 
the  chest,  especially  among  those  under  whose  care  they  came  soon 
after  the  injury  was  received.  Several  cases  that  looked  most  en- 
couraging shortly  after  being  wounded  later  developed  serious  com- 
plications. 

"  Noting  one  or  two  such  instances,  I  began  to  collect  the  his- 
tories of  as  many  cases  as  I  could  find  recorded  by  the  different 
surgeons  who  attended  them.  I  have  been  able  to  collect  the  his- 
tories of  24  cases  as  they  were  sent  in  separately  to  the  Surgeon- 
General's  office  by  these  surgeons,  and  of  these,  15  recovered  with- 
out complications,  3  had  hemothorax  without  going  on  to  formation 
of  empyema,  and  6  developed  hemothorax  which  eventually  became 
purulent  and  required  operation.  One  out  of  this  latter  number 
had  peritonitis  and  died. 

"The  histories  of  these  cases  were  as  follows  : 

"  Case  i. — Winslow  Clark,  Company  G,  First  Volunteer  Cavalry,  was  wounded  July 
1st  by  a  Mauser  bullet  which  perforated  the  left  scapula  through  the  infraspinous  fossa, 
three  inches  above  the  angle  and  an  inch  from  the  spinal  border.  No  exit.  The  prob- 
able course  of  the  bullet  was  downward  and  forward  into  chest.  There  were  some 
hemoptysis  and  fever,  but  no  vomiting  of  blood.  The  hemothorax  was  quite  extensive 
and  was  relieved  by  thoracentesis,  performed  a  week  after  the  injury  was  received.  He 
recovered  without  further  complications. 

"  Cask  2.— Harry  Mitchell,  Company  C,  Seventh  Infantry,  was  wounded  on  July  1st 
by  a  Mauser  bullet  which  entered  over  the  acromion  process  of  the  left  scapula,  passed 
through  the  apex  of  the  left  lung,  mediastinum,  and  right  lung,  and  having  its  wound 
of  exit  in  the  second  interspace,  right  nipple-line.  There  was  no  hemoptysis  at  any  time, 
though  a  slight  hemothorax  developed  on  the  right  side,  with  some  dry  cough.  He  at 
that  time  had  fever,  which  was  promptly  controlled  by  quinin,  and  his  spleen  was  greatly 
enlarged.      The  recovery  from  this  wound  was  complete  without  surgical  interference. 

"Case  3— Lieutenant  Nair,  Eighth  Infantry,  was  wounded  at  the  battle  of  El 
Caney  by  a  bullet  that  passed  through  the  left  chest,  of  the  exact  location  of  which  I 
am  not  informed.  There  was  considerable  hemoptysis  immediately  after  the  wound  was 
received,  which  persisted  for  a  few  days.  The  wounds  of  exit  and  entrance  healed. 
Later,  at  the  general  hospital  at  P'ort  Monroe,  there  was  found  flatness  ovi-r  the  left  chest, 
with  all  the  signs  of  an  effusion  into  the  pleura.  'J'his  was  asjiirated  off  and  a  large  quan- 
tity of  serosanguineous  fluid  withdrawn.  Later  this  was  again  repeated,  with  the  same 
result.  Eventually  signs  of  sapremia  were  present,  so  an  incision  was  made  and  a  large 
empyema  opened  into.     Recovery  followed  this  operation. 


268  GUNSHOT    WOUNDS. 

"  Case  4. — John  B.  Senica,  Company  G,  Twenty-second  Infantry,  on  July  1st  was 
wounded  by  a  Mauser  bullet  which  entered  the  back,  just  below  the  angle  of  the  left 
scapula,  passed  up  through  the  lung,  neck,  and  jaw,  and  emerged  through  the  alveolar 
process  of  the  right  bicuspid  tooth.  Both  woitnds  healed  by  primary  intention.  Just 
after  the  wound  was  inflicted  he  had  profuse  hemoptysis,  which  lasted  for  a  few  days. 
There  were  loss  of  power  of  the  left  arm,  which  disappeared  gradually,  and  numbness 
and  tingling  in  the  fingers  and  desquamation  of  the  skin  on  the  left  hand.  While  on 
the  Relief  his  temperature  was  normal,  condition  generally  good,  and  on  the  twentieth 
day  after  the  injury  he  was  allowed  to  sit  up  for  a  short  time  each  day.  When  admitted 
to  the  Long  Island  College  Hospital  his  temperature  was  102°  F.  ;  there  was  consid- 
erable dyspnea.  On  August  2d  thoracentesis  yielded  nothing.  On  August  22d  the 
symptoms  demanded  a  more  radical  operation,  so  two  inches  of  rib  from  the  seventh  rib 
were  exsected  and  eight  ounces  of  pus  were  removed,  with  fragments  of  disintegrated 
clot.      Recovery  followed  this  operation. 

"Case  5. — Report  of  a  Case  at  Long  Island  College  Hospital. — A  Rough  Rider 
was  wounded  on  July  1st  by  a  Mauser  bullet  which  perforated  the  right  forearm  and  the 
arm,  fracturing  the  humerus,  entering  the  chest  just  below  the  axilla,  and  emerging  be- 
tween the  seventh  and  eighth  ribs,  near  their  vertebral  attachment,  causing  a  compound 
fracture  of  the  eighth  rib,  right  side,  at  its  angle,  and  lodging  beneath  the  skin.  On  the 
27th  he  was  admitted  to  the  hospital  with  fever  ranging  from  100°  F.  to  103°  F. ,  had 
harsh,  dry  cough  and  great  dyspnea,  with  signs  of  an  effusion  in  left  pleura.  Thora- 
centesis on  July  1st  yielded  one  pint  of  a  serosanguineous  fluid.  On  July  22d  an  in- 
cision over  the  eighth  rib  recovered  the  leaden  core  of  the  bullet  ;  the  incision  was 
extended  into  the  pleura,  and  two  pints  of  purulent  fluid  escaped.  On  August  loth  the 
seventh  and  eighth  ribs  were  resected,  and  a  large  quantity  of  debris,  clot,  etc.,  was 
removed,  and  the  jacket  of  the  bullet  was  found  and  removed.      Patient  recovered. 

"  Case  6. — Arthur  W.  Fairbrother,  Company  C,  Third  Cavalry,  on  July  1st  was 
wounded  by  a  Mauser  bullet  which  entered  just  below  the  middle  of  the  right  clavicle, 
with  no  wound  of  exit.  There  was  hemoptysis,  which  subsided  after  the  first  few  days. 
Soon  after  this  there  was  an  irregular  rise  of  temperature,  with  the  beginning  signs  of 
an  effusion  into  the  right  pleura  and  a  return  of  the  bloody  expectoration.  On  admis- 
sion to  the  Relief  about  July  12th  he  had  a  large  eftusion  in  the  pleura.  The  wound  of 
entrance  was  not  completely  closed,  and  discharged  dark  blood  on  coughing.  The 
sputum  was  thick  and  suggested  a  pneumonia  ;  temperature  was  very  high  and  there 
was  great  dyspnea.  Paracentesis  was  perfomied  about  July  20th,  and  about  three  pints 
of  dark-red  colored  fluid  drawn  off,  after  which  there  still  remained  a  large  collection 
of  material  in  the  pleura,  and  the  patient  improved  slightly,  but  only  temporarily. 
On  July  27th  he  was  admitted  to  St.  Peter's  Hospital,  Brooklyn.  The  wound  had 
closed,  and  the  patient  exhibited  the  same  symptoms  as  formerly,  in  an  exaggerated 
form,  the  pleura  having  filled  up  again.  An  exploratory  puncture  was  made,  and  an 
empyema  was  found  to  have  developed,  for  which  reason  the  resection  of  a  rib  was  nec- 
essary. This  was  done  posteriorly,  and  a  large  quantity  of  pus,  clotted  blood,  and 
exudate  was  removed,  and  an  unsuccessful  search  for  the  bullet  was  made.  The  dis- 
charge was  copious  for  a  long  time,  but  gradually  diminished,  and  the  patient  was 
granted  a  furlough  on  September  loth,  much  improved.  While  lying  in  the  field-hospital 
in  Cuba  he  was  greatly  exposed  to  wettings  and  bad  climate. 

"Case  7. — Henry  P.  Darby,  Company  D,  Thirteenth  Infantry,  on  July  1st  was 
wounded  by  a  Mauser  bullet  which  perforated  the  left  arm  and  entered  the  left  side  of 
the  thorax,  fracturing  the  fourth  rib  in  the  axillary  line.  It  penetrated  both  lungs  and 
escaped  from  the  right  side  of  the  thorax,  between  the  fourth  and  fifth  ribs,  in  the  posterior 
axillary  line.  After  being  wounded  he  was  subjected  to  considerable  exposure  before 
reaching  the  General  Hospital  at  Siboney,  Cuba.  There,  when  seen  on  about  July  loth, 
his  temperature  was  about  103.6°  F.  Respiration  was  labored  and  very  rapid,  the  heart 
was  displaced  well  over  to  the  right  of  the  sternum,  and  there  was  absolute  flatness  over 
the  entire  left  chest.  Thoracentesis  yielded  fluid  blood,  only  a  small  quantity  of  which 
could  be  removed.  Tater  this  became  purulent,  and  Estlander's  operation  was  finally 
necessary  for  his  recovery. 

"  Case  8. — James  Scanlon,  Company  K,  Third  Cavalry,  was  wounded  on  July 
2d  by  a  Mauser  bullet  which  entered  the  right  side  of  the  thorax  over  the  third  rib,  in 
the  midclavicular  line,  passed  downward  and  backward  through  lungs,  diaphragm,  liver, 
and  abdominal  cavity,  pierced  the  right  iliac  bone,  and  emerged  from  the  gluteal  region. 
He  had  but  little  hemoptysis.  He  lay  in  the  division  hospital  for  some  time  on  the 
wet  ground,  and  was  exposed  to  the  worst  conditions  of  weather.  On  admission  to  the 
Relief  he  had  great  pain  over  the  right  chest  and  over  the  entire  abdomen  ;  nausea  and 
vomiting,  dysentery,  and  great  dyspnea  were  present,  and  his  temperature  was  hectic. 
The  patient  eventually  died  of  peritonitis  and  pyohemothorax. 


GUNSHOT  WOUNDS  OF  THE  CHEST.  269 

"Case  9. — Case  XVI.  Mauser  bullet  entered  the  sixth  interspace  in  the  posterior 
axillar)'  line,  and  emerged  in  the  corresponding  interspace  on  the  opposite  side.  There 
were  some  dyspnea  and  hemoptysis,  with  slight  effusion  into  the  left  pleura.  There  was 
no  fever  to  indicate  any  purulent  collection,  and  recovery  followed  without  complications 
of  any  kind. 

"Case  10. — Case  XV  at  Long  Island  College  Hospital.  Wounded  by  a  Mauser 
bullet  which  entered  over  the  eighth  rib  in  the  posterior  axillary  line,  and  there  is  no 
wound  of  exit.  The  bullet  was  never  removed,  and  there  were  no  resulting  chest  com- 
plications. 

"  Case  ii. — Otto  Hornlein,  Company  C,  Fourth  Infantry,  was  wounded  in  left 
chest,  but  probably  only  superficially,  without  wounding  the  pleura.  There  was  no 
hemoptysis,  and  the  wound  over  the  chest  healed  quickly. 

"Case  12. — John  Taylor,  Company  D,  Tenth  Cavalry,  was  wounded  at  about  200 
yards  distance,  the  bullet  entering  just  below  the  angle  of  the  left  scapula.  It  then 
lodged  itself  in  the  abdominal  muscles,  about  two  inches  from  the  umbilicus.  He  had 
hemoptysis  for  several  days.      He  made  an  uninterrupted  recovery. 

"  Case  13. — Ernest  Bender,  Company  I,  First  Cavalry,  was  wounded  through  the  left 
chest ;  he  made  a  complete  and  uneventful  convalescence.  No  very  detailed  history  of 
his  injury  was  received. 

"  Case  14. — Edward  O' Flaherty,  Company  C,  Sixteenth  Infantry,  was  wounded  on 
July  2d  by  a  45 -caliber  ball  from  a  bursting  shrapnel,  which  entered  below  the  angle 
of  the  right  scapula  and  lodged  beneath  the  skin  in  front,  between  the  seventh  and  eighth 
ribs,  after  having  traveled  through  the  lung,  diaphragm,  and  liver.  The  patient  had 
hemoptysis  for  several  days,  with  some  rise  of  temperature,  which  had  completely  sub- 
sided in  ten  days  from  the  time  of  injury,  and  no  pleural  or  peritoneal  effusion  resulted. 
He  was  discharged  from  the  Long  Island  City  College  Hospital  cured. 

"  Case  15. — William  J.  Mclntyre,  Company  F,  .Seventh  Infantry,  was  wounded  by  a 
Mauser  bullet  at  about  50x3  yards  range,  which  entered  just  above  the  middle  of  the  clav- 
icle, and  had  its  exit  just  below  the  tip  of  the  scapula.  There  was  some  hemoptysis  im- 
mediately after  receiving  the  wound,  but  convalescence  was  entirely  uncomplicated  and 
complete. 

"Case  16. — Case  7  (see  'Medical  News').  Wounded  by  a  Mauser  bullet  that 
entered  the  left  side  of  the  neck,  one-half  inch  external  to  the  median  line,  opposite  the 
thyroid  gland,  and  made  its  exit  on  the  right  side  of  the  chest  at  the  fifth  rib,  opposite 
the  posterior  axillary  line.  This  fractured  the  clavicle  at  the  inner  third,  and  caused 
an  arteriovenous  aneurysm.  No  pulmonary  symptoms  other  than  slight  hemoptysis  de- 
veloped, and  recovery  was  perfect. 

"Case  17. — William  A.  Cooper,  Company  A,  Tenth  Cavalry,  was  wounded  by  a 
Mauser  bullet  that  entered  the  flesh  over  the  chest,  one  inch  to  the  right  of  the  left  nipple, 
and  made  its  exit  one  inch  below  the  costal  margin  on  the  right  side  in  the  mammary 
line.  It  is  just  possible  that  it  did  not  wound  the  pleura  at  all,  though  at  a  very  late 
date  the  history  of  hemoptysis  was  elicited  from  the  patient.  His  chest  injuries  healed 
promptly  and  without  any  resulting  complications,  but  an  intercurrent  dysentery  confined 
him  to  his  bed  for  some  time. 

"  The  histories  of  seven  other  cases  were  secured  whose  wounds 
healed  promptly  without  complications.  These  are  so  similar  to 
the  above-recorded  cases  that  room  is  not  taken  to  inckuie  them  in 
this  report. 

"  From  the  cases  here  presented  we  are  at  once  impressed  with 
the  fact  that  while  the  effect  of  the  modern  gunshot  injury  is 
humane  as  compared  with  the  old  leaden  bullet,  there  is  a  sufficient 
percentage  that  develop  hemothorax  and  empyema  greatly  to 
modify  this  claim.  Out  of  24  cases,  we  have  9,  or  nearly  7,8  per 
cent.,  with  most  serious  results.  There  may  be  many  more  who 
promptly  recovered,  and  certainly  only  a  very  few  more,  if  any,  who 
had  hemothorax  or  empyema. 

"  In  the  .Santiago  campaign  the  wounded  had  to  be  carried  in 
ambulances,  over  roads  that  baffle  description,  in  order  to  reach  the 
hospital  at  Siboney,  and  this  was  done  some  eight  or  ten  days  after 


2/0  GUNSHOT    WOUNDS. 

the  wounds  were  received.  Moreover,  while  in  the  division  hospi- 
tals on  the  San  Juan  River  they  were  but  poorly  sheltered  and 
subjected  to  very  severe  weather,  two  conditions  that  would  most 
favor  continued  bleeding  on  the  one  hand,  and  infection  on  the 
other.  Illustrative  of  this  we  have  in  cases  i,  2,  3,  4,  5,  6,  7,  8, 
and  9  the  development  of  hemothorax,  which  in  most  instances 
was  not  discovered  until  twelve  or  fourteen  days  after  the  wounds 
were  received,  and  it  was  more  than  likely  that  prior  to  this  time 
they  did  not  exist  to  any  marked  degree,  but  formed  gradually, 
because  of  the  inability  to  maintain  perfect  quiet  and  rest  in  their 
treatment.  In  three  of  these  cases,  i,  2,  and  9,  the  blood  in  the 
pleura  was  absorbed  without  becoming  infected,  and  in  all  the 
others  (excepting  cases  6  and  8)  the  breaking-down  of  the  hemo- 
thorax to  form  pus  was  a  late  complication.  Thoracentesis  showed 
blood  only  as  late  as  the  twentieth  day  in  case  4,  nineteenth  day  in 
case  5,  tenth  day  in  case  7,  and  in  case  2  blood  only  when  he 
arrived  at  the  hospital  at  Fort  Monroe.  In  each  of  these  cases, 
however,  operation  was  ultimately  necessary  for  empyema.  In  all 
except  case  6  the  external  wound  of  entrance  and  of  exit  had 
healed  promptly  and  the  patient  had  no  symptoms  that  would 
indicate  infection  at  the  time  of  injury.  Case  6  might  have  been 
no  exception  to  this  had  he  not  had  to  lie  on  the  ground  exposed 
to  wet  and  cold  shortly  after  being  injured.  From  these  facts  it 
seems  evident  that  the  cause  of  infection  of  this  collection  of  blood 
in  the  pleura  was  not  from  the  bullet  dirdctly,  but  that  the  micro- 
organisms gained  access  to  this  fertile  soil  from  the  wounded  lung. 
In  case  5  we  find  that  the  development  of  empyema  after  the  nine- 
teenth day  was  on  the  side  opposite  to  the  wound  of  entrance. 

"  These  facts  point  clearly  to  most  important  suggestions  in  the 
treatment  of  all  chest  injuries  in  time  of  war.  They  are  always  to 
be  looked  upon  as  most  dangerous  wounds,  especially  in  the  eyes  of 
the  soldier  himself,  so  that  they  Avill  be  handled  with  special  care 
from  the  time  of  injury.  The  utmost  care  must  be  observed  in  their 
treatment  for  several  weeks  until  all  danger  of  further  hemorrhage 
into  the  pleura  is  past. 

"The  indications  for  treatment  are  twofold:  First,  to  guard 
against  infection  at  this  time,  when  conditions  are  so  favorable  for 
that  serious  complication  ;  and,  second,  to  check  hemorrhage  as 
soon  as  possible,  for  a  collection  of  blood  in  the  pleura  or  a  hemato- 
cele in  the  lung  is  a  most  fertile  ground  for  saprophytic  invasion 
and  acts  itself  as  a  foreign  irritant.  The  first  is  met  by  promptly 
cleansing  and  applying  the  first-aid  sterile  dressing,  and  using 
special  precautions  during  convalescence  to  prevent  exposure  and 
conditions  that  would  lead  to  any  general  inflammation  of  the 
lungs.  We  know  that  a  bronchitis,  pneumonia,  or  any  inflam- 
matory state  of  the  lungs  renders  them  more  favorable  soil  for 
the  ever-present  micro-organisms,  and  soon  breeds  them  into  their 
more  virulent  form,  thus   greatly  favoring  the  eventual  formation 


GUNSHOT    WOUNDS    OF    THE    CHEST.  2/1 

of  empyema  or  lung  abscess,  especially  when  there  has  been  bleed- 
ing. 

"  The  second  indication  is  met  by  making  it  thoroughly  under- 
stood, especially  among  the  soldiers  themselves,  that  all  chest 
wounds  are  serious.  The  patient  must  be  kept  absolutely  quiet 
and  passive,  avoid  talking  and  active  motion  of  any  kind,  and  must 
be  transferred  with  the  gentlest  care,  preferably  on  a  litter,  over 
rough  ground.  The  surgeon  will  employ  the  usual  methods  of 
controlling  internal  hemorrhages  by  the  strapping  of  the  injured 
side,  the  use  of  opium  to  put  it  to  rest,  the  administration  of  inter- 
nal astringents,  the  local  use  of  cold,  enforced  use  of  bed-pan,  etc. 

!' Undoubtedly  we  have  in  chest  injuries  a  condition  that  calls 
for  more  extraordinary  care  and  painstaking  than  other  injuries  of 
greater  apparent  severity,  to  prevent  a  fatal  or  a  most  serious  and 
deforming  result." 

Careful  investigation  of  these  cases  so  remotely  from  the  time 
of  injury  is  of  great  value  in  showing  that  patients  suffering  from 
penetrating  wounds  of  the  chest  should  be  handled  with  the  ut- 
most care,  and  should  never  be  transported  beyond  the  distance 
absolutely  necessary,  as  otherwise  the  internal  bleeding  is  increased. 
Rest  constitutes  an  important  element  in  the  treatment  of  such 
cases.  Stimulants  must  be  withheld  until  the  hemorrhage  has 
been  spontaneously  arrested.  Aspiration  is  contraindicated  until 
the  bleeding  has  ceased,  as  the  intrathoracic  compression  by  the 
extravasated  blood  constitutes  an  important  hemostatic  agent.  The 
late  infection  in  some  of  the  cases  gathered  by  Greenleaf  can  un- 
doubtedly be  explained  by  the  prevalence  of  complicating  inter- 
current affections  and  the  debilitating  influence  of  the  Cuban 
climate,  together  with  the  quality  of  the  rations. 

We  have  made  but  little  progress  in  the  treatment  of  penetrating 
wounds  of  the  chest.  Direct  operative  treatment  of  visceral  wounds 
of  the  heart  and  lungs  is  always  attended  by  imminent  risk  to  life 
from  pulmonary  collapse.  This  source  of  danger  stands  in  the  way 
of  direct  treatment  of  visceral  wounds  of  the  chest.  Hemorrhage 
from  wounds  of  the  lung  is  often  arrested  spontaneously  by  accu- 
mulation of  blood  in  the  cavity  of  the  chest,  causing  temporary  pul- 
monary collap.se  and  tamponade  of  the  tubular  visceral  wound  by 
the  formation  of  a  blood-clot.  Free  incision  of  the  chest-wall  has 
been  strongly  advocated  by  several  French  surgeons  in  cases  of 
penetrating  gunshot  wounds  of  the  chest,  with  a  view  to  arresting 
hemorrhage  by  ligation,  tamponade,  or  the  use  of  the  cautery,  but 
the  profession,  on  the  whole,  for  good  reasons,  is  opposed  to  such 
heroic  treatment.  Unless  the  source  of  hemorrhage  is  one  of  the 
intercostal  or  the  internal  mammary  arteries,  it  is  advisable  to  rely 
on  nature's  resources,  aided  by  such  means  as  will  favor  thrombus 
formation  in  arresting  the  bleeding.  Hemorrhage  from  the  inter- 
costal arteries  can  be  quickly  and  effectually  arrested  by  tamponade, 


2/2 


GUNSHOT    WOUNDS. 


using  for  this  purpose  an  hour-glass-shaped  tampon  of  iodoform 
gauze  in  a  mantle  or  bag  of  the  same  material  (Fig.  i68). 

When  I  devised  this  method  of  tamponade  for  this  special  pur- 
pose, I  had  no  knowledge  that  von  Langenbeck  had  previously- 
made  a  similar  suggestion.  Rest  in  the  recumbent  position,  with 
the  chest  slightly  elevated,  is  essential  in  aiding  spontaneous  arrest 
of  hemorrhage.  The  internal  use  of  veratrum  viride  and  other 
heart  depressants,  if  given  early,  contributes  in  the  same  direction. 
Fixation  of  the  chest  by  a  circular  bandage  limits  the  movements 
of  the  chest,  and  thus  secures  rest  for  the  wounded  organ. 

A  rise  in  the  temperature  during  the  first  forty-eight  hours  is  no 
indication  of  the  existence  of  infection,  as  with  few  exceptions  it 
points  to  a  febrile  disturbance  caused  by 
the  absorption  of  fibrin  ferment,  the  so- 
called  fermentation  fever.  The  production 
of  an  artificial  pneumothorax  or  hydro- 
thorax  by  the  introduction  into  the  pleural 
cavity  of  a  nontoxic  gas  or  filtered  atmos- 
pheric air  or  sterilized  water  has  not  proved 
satisfactory  in  the  treatment  of  intrathoracic 
traumatic  hemorrhage.  Aspiration  of  the 
contents  of  the  chest  must  be  postponed 
until  spontaneous  hemostasis  is  assured — 
that  is,  never  before  the  third  or  the  fifth 
day.  In  performing  this  operation  the 
strictest  aseptic  precautions  must  be  ob- 
served, and  aspiration  limited  to  the  re- 
moval of  only  so  much  of  the  extravasation 
as  will  relieve  the  embarrassed  circulation. 
No  unnecessary  suction  force  must  be  used, 
for  fear  of  causing  a  recurrence  of  hemor- 
rhage. Should  later  symptoms  set  in  suggestive  of  septic  infec- 
tion, aspiration  should  be  promptly  resorted  to,  and  if  not  followed 
by  speedy  improvement,  no  time  should  be  lost  in  subjecting 
the  patient  to  the  same  surgical  treatment  as  is  advised  and  prac- 
tised for  empyema  from  other  causes — that  is,  rib  resection,  free 
incision,  and  drainage.  Penetrating  wounds  of  the  chest  should  never 
be  explored  with  finger  or  instruments.  They  constitute  in  recent 
cases  a  noli  me  tangere  in  surgery. 

From  what  has  been  said  it  is  clear  that  the  best  treatment  in 
penetrating  wounds  of  the  chest  consists  in  hermetically  sealing  the 
wound  of  entrance  and  of  exit,  if  the  latter  exists,  under  strict  asep- 
tic precautions,  immobilization  of  the  chest  by  bandaging  and  rest, 
and  in  watching  for  and  treating  subsequent  complications  as  they 
arise. 


Fig.  \i 


-Tamponade 


of    intercostal   artery    (after 
Von  Langenbeck) 


GUNSHOT    WOUNDS    OF    THE    ABDOMEN.  2/3 

GUNSHOT  WOUNDS  OF  THE  ABDOMEN. 

Modern  surgery  has  probably  done  more  for  the  successful 
treatment  of  visceral  wounds  of  the  abdominal  organs  than  for  injuries 
of  any  of  the  organs  cojitained  in  the  remaining  large  cavities  of  the 
body.  The  triumphs  that  have  signalized  the  practice  of  civilian  sur- 
geons in  the  operative  treatment  of  intra-abdominal  injuries  will  be 
repeated,  on  a  more  limited  scale,  on  the  battle-field.  I  look  hope- 
fully for  many  successful  results  in  the  operative  treatment  of  gun- 
shot wounds  in  military  practice,  although  experience  so  far  does 
not  seem  to  strengthen  such  an  expectation.  Four  laparotomies  for 
perforating  gunshot  wounds  of  the  abdomen  were  performed  in  the 
First  Division  Hospital,  the  only  ones,  to  my  knowledge,  during 
the  Cuban  campaign.  All  the  patients  died.  This  unfavorable  expe- 
rience should  not  deter  surgeons  from  performing  the  operation  in 
the  future  in  cases  in  which,  owing  to  the  course  of  the  missile,  it  is 
reasonable  to  assume  that  the  bullet  has  made  visceral  injuries  that 
would  be  almost  certain  to  destroy  life  without  surgical  inter- 
ference. 

There  are  so  many  circumstances  in  military  practice  that  mili- 
tate against  the  propriety  and  feasibility  of  resorting  to  formidable 
surgical  interference  in  such  cases  that  it  becomes  necessary  to 
restrict  the  indications  much  more  than  in  civil  practice,  with  a  view 
to  securing  the  greatest  benefits  for  the  wounded  and  to  maintaining 
the  good  reputation  of  the  medical  service.  My  remarks  in  this 
section  will  apply  almost  exclusively  to  penetrating  wounds,  taking 
it  for  granted  that  when  patients  are  brought  to  the  field-hospitals, 
the  surgeons  in  charge  will  consider  it  their  imperative  duty  to 
make  a  positive  diagnosis  between  penetrating  and  nonpenetrating 
wounds  before  assuming  the  responsibility  of  opening  the  abdomen. 
In  the  discussion  of  this  subject  I  shall  quote  freely  from  the  forth- 
coming third  edition  of  the  "  American  Text-book  of  Surgery," 
from  the  section  devoted  to  abdominal  surgery. 

Sword,  bayonet,  and  other  stab  wounds  will  diminish  in  fre- 
quency with  the  development  of  modern  scientific  warfare.  The 
penetrating  wounds  of  the  abdomen  that  will  come  under  the 
ob.servation  of  the  military  surgeon  will,  with  few  exceptions,  be 
wounds  inflicted  with  the  modern  small-caliber  projectile.  The 
visceral  wounds  and  the  wounds  of  entrance  and  exit  will  be  small 
— too  small  for  digital  exploration.  It  is  perhaps  superfluous  to 
make  the  statement  here  that  a  penetrating  wound  of  the  abdomen 
should  never  be  probed  either  for  diagnostic  or  for  tJierapeutic  purposes. 
If  any  doubt  exists  as  to  whether  or  not  the  bullet  has  entered  the 
abdominal  cavity,  it  is  far  better  and  safer  to  dilate  the  track  by  the 
use  of  the  knife,  relying  on  the  probe  or  grooved  director  as  a 
guide,  than  to  work  in  the  dark  with  the  probe  and,  by  doing  so, 
incrca.sc  the  possibilities  of  infecting  the  peritoneal  cavity.  Quite 
recently  the  assertion  has  been  made  by  several  prominent  surgeons 
i8 


274 


GUNSHOT    WOUNDS. 


that  laparotomy  should  be  performed  in  all  cases  in  which  it  can  be 
shown  that  penetration  has  occurred.  It  must,  however,  be  ad- 
mitted that,  in  the  absence  of  serious  visceral  lesions,  penetrating 
wounds  of  the  abdomen  are  injuries  from  which  the  patients  are 
very  likely  to  recover  without  operative  treatment,  and  that  when 
such  patients  are  subjected  to  laparotomy  and  prolonged  search  for 
visceral  lesions,  death  may  occur  solely  in  consequence  of  the  oper- 
ation. It  is  undoubtedly  true  that  in  most  cases  of  spontaneous 
recovery  after  penetrating  gunshot  wound  of  the  abdomen  the 
favorable  termination  has  been  due  to  the  absence  of  serious  visceral 
lesions,  which  some  hold  to  be  invariably  present  in  such  cases.  A 
number  of  years  ago  I  made  a  series  of  experiments  on  the  cadaver 
for  the  purpose  of  demonstrating  that  occasionally  a  bullet  can 
traverse  the  abdominal  cavity  in  certain  directions  without  producing 
a  visceral  wound  that  would  warrant  a  laparotomy.  The  cadaver, 
a  marasmic  adult  male,  was  placed  in  the  erect  position  against  a 
wall,  and  the  shooting  was  done  with  a  38-caliber  rifle  at  a  dis- 
tance of  thirty  feet.  The  bullet  was  fired  in  every  instance  in  an 
anteroposterior  direction,  and  invariably  passed  through  the  body. 
Sixteen  shots  were  fired,  and  examination  of  the  abdominal  cavity, 
carefully  made  by  following  the  track  of  each  bullet,  showed  that 
four  of  the  bullets  traversed  the  abdominal  cavity  without  injuring 
the  stomach,  intestines,  or  any  of  the  large  abdominal  vessels.  In 
each  of  these  four  instances  the  bullet  entered  the  abdomen  at 
or  a  little  above  the  umbilical  level.  In  all  cases  in  which  the 
bullet  entered  below  the  umbilical  level  intestinal  perforations  were 
found.  Absence  of  visceral  lesions  has  also  been  demonstrated  dur- 
ing operations  and  at  postmortems.  During  the  Greco-Turkish  war 
several  cases  of  gunshot  wounds  of  the  abdomen  recovered  under  a 
conservative  plan  of  treatment.  In  nearly  all  these  cases  the  bullet 
entered  the  abdomen  above  the  umbilicus,  the  most  favorable 
location  for  the  escape  of  intestines  from  the  missile,  the  patients 
being  in  a  standing  position. 

Under  the  head  of  gunshot  wounds  of  the  chest  I  reported  two 
cases  in  which  the  bullet  at  the  same  time  invaded  the  peritoneal 
cavity,  and  both  of  these  cases  recovered  without  operative  inter- 
ference. I  saw  a  number  of  cases  of  perforating  wounds  of  the 
abdomen  in  the  First  and  Third  Division  Hospitals  in  front  of  San- 
tiago that  were  on  a  fair  way  to  recovery  without  operation  before 
they  were  sent  home  on  transport  ships.  In  most  of  these  instances 
the  bullet  wounds  were  either  in  the  umbilical  region  or  in  one  of 
the  iliac  fossae.  The  folloAving  case  presents  features  of  more  than 
usual  clinical  and  surgical  interest : 

Case  i. — ^J.  F.  Taylor,  Company  D,  Tentli  Cavalry,  was  wounded  July  2d.  At  the 
time  the  injury  was  received  he  was  in  the  ventral  prone  position.  The  bullet  entered 
the  left  shoulder,  in  the  infraspinous  fossa,  one  inch  below  the  spinous  process  of  the 
scapula,  and  passed  downward  and  inward,  lodging  under  the  skin  in  the  median  line, 
two  inches  above  the  umbilicus.  Hemoptysis  was  considerable  during  the  first  day, 
when  it  gradually  subsided.      He  complained  of  great  pain  and  tenderness  in  the  right 


GUNSHOT    WOUNDS    OF    THE    ABDOMEN.  2/5 

side  of  the  abdomen.  No  vomiting  occuiTed,  nor  were  there  symj)toms  of  more  than 
a  circumscribed  peritonitis.  An  abscess  formed  in  the  abdominal  wall,  which  was  opened 
July  20th  and  the  bullet  removed.     From  this  time  on  the  patient  improved  rapidly. 

During  the  Civ'il  War  an  occasional  .recovery  from  gunshot 
wounds  in  the  region  of  the  stomach  and  large  intestine  was 
observed,  while  penetrating  wounds  in  the  small  intestinal  area, 
with  few  exceptions  indeed,  proved  fatal.  Dr.  D.  R.  Brower  recol- 
lects distinctly  a  very  unusual  case  that  came  under  his  own  ob- 
servation. A  young  soldier  was  admitted  to  the  hospital  who  a 
few  hours  before  had  been  shot  in  the  region  of  the  umbilicus. 
Only  one  wound  was  found,  and  this  corresponded  exactly  to  the 
umbilicus.  It  was  thought,  judging  from  the  mildness  of  the  symp- 
toms, that  the  wound  was  not  a  penetrating  one.  The  injury  was 
followed  by  a  circumscribed  peritonitis,  and  two  weeks  later  the 
bullet  was  found  in  the  fecal  discharges.  It  is  possible  that  in  this 
case  the  bullet  did  not  penetrate  the  transverse  colon,  but  found  its 
way  into  it  later,  with  the  contents  of  a  circumscribed  abscess. 

Wounds  of  the  empty  stomach  inflicted  by  small-caliber  bullets 
frequently  heal  without  operative  intervention,  an  observation  well 
established  by  many  well-authenticated  cases  in  civil  as  well  as  in 
military  practice.  The  following  cases  of  penetrating  wounds  of  the 
abdomen  that  recovered  without  primary  operation  came  to  my 
notice  during  the  Greco-Turkish  war  : 

Case  2.  —  Gunshot  Wound  of  Abdomen  and  Chest. — Greek  soldier.  Bullet  entered 
dorsal  side  of  chest  on  a  level  with  the  eighth  rib,  four  inches  from  the  median  line  ;  it 
took  a  downward  and  forward  course,  and  escaped  below  the  costal  arch,  an  inch  below 
the  cartilage  of  the  seventh  rib.  No  operation  was  performed.  Bile  escaped  through 
the  anterior  perforation  for  a  number  of  days.  The  wound  healed  without  suppuration. 
There  were  no  serious  inflammatory  complications,  and  the  patient  became  fully  con- 
valescent. 

Case  3. — Greek  soldier.  Bullet  passed  through  the  abdomen  a  little  to  the  right  of, 
and  an  inch  above,  the  umbilical  level.     Recovery  followed  without  operation. 

Both  of  these  cases  entered  the  hospital  a  week  after  the  injury 
was  received. 

In  the  military  hospitals  at  Constantinople  I  found  the  following 
cases  : 

Case  4.  —  Gunshot  Wound  of  Ri^ht  Iliac  Fossa. — Bullet  entered  one  inch  above 
Poupart's  ligament,  to  the  outer  side  of  the  large  blood-vessels,  and  escaped  through  the 
perineum  on  the  same  side.  Intestinal  fistula  remained.  The  use  of  the  limb  was  not 
much  impaired. 

Case  5. — Volunteer,  thirteen  years  old,  received  a  wound  of  the  right  iliac  fossa. 
Infection  ffiljowed  the  injury,  and  resulted  in  the  formation  of  a  large  ]KMityphlitic 
abscess,  which  was  later  incised  and  drained.  Rapid  recovery  ensued.  The  boy  soldier 
was  much  emaciated  and  very  anemic,  but  was  able  to  walk  about  the  hospital  grounds. 

It  will  be  seen  from  the  foregoing  cases  that  the  bullet  traversed 
the  abdominal  cavity,  either  at  or  above  the  umbilical  level,  or  one 
of  the  iliac  fossae — that  is,  localities  occupied  by  the  stomach  or 
large  intestine. 

In  two  out  of  sixteen  cases  of  penetrating  gunshot  \\'ounds  of 
the  abdomen  that  came  under  my  observation,  the  absence  of  visceral 
injuries  of  the  gastro-intestinal  canal  was  demonstrated  by  the  use  of 


2/6  GUNSHOT    WOUNDS. 

the  hydrogen  gas  test,  and  both  of  these  patients  recovered  without 
resort  to  laparotomy.  Clinical  experience  and  the  result  of  experi- 
ment show  conclusively  that  laparotomy  should  not  be  performed 
simply  because  a  bullet  has  entered  the  abdominal  cavity,  but  that 
its  performance  should  be  limited  to  the  treatment  of  intra-abdominal 
lesions  that,  without  operative  interference,  would  tend  to  destroy 
life.  A  bullet  which  passes  through  the  lower  part  of  the  abdomen 
from  side  to  side  or  obliquely  is  almost  sure  to  produce  from  four  to 
fourteen  perforations  of  the  intestines,  while  absence  of  dangerous 
visceral  complications  may  be  inferred  with  some  degree  of  proba- 
bility if  it  crosses  the  abdominal  cavity  in  an  anteroposterior  direc- 
tion at,  or  a  little  above,  the  umbilical  level. 

Symptoms. — The  general  symptoms  in  cases  of  penetrating 
gunshot  wounds  of  the  abdomen,  with  the  exception  of  those  due 
to  profuse  hemorrhage,  furnish  very  little  information  in  reference 
to  the  existence  or  absence  of  visceral  complications.  Severe  shock 
may  attend  a  single  nonpenetrating  wound,  and  it  may  be  absent,  or 
at  least  slight,  in  cases  of  multiple  perforation  of  the  intestines.  It 
is  not  an  uncommon  occurrence  for  a  patient  who  has  received  a 
penetrating  wound  of  the  abdomen  to  walk  several  blocks,  or  even 
a  number  of  miles,  without  a  great  deal  of  suffering  and  without 
showing  any  symptoms  of  shock,  and  yet  for  a  number  of  intestinal 
perforations  to  be  revealed  at  a  subsequent  operation  or  autopsy. 
Vomiting  occurs  quite  as  frequently  in  parietal  wounds  and  in 
simple  penetrating  wounds  as  when  the  viscera  have  been  injured. 
Vomiting  of  blood  points  to  the  existence  of  a  wound  of  the 
stomach. 

Pallor  is  present  in  all  penetrating  wounds  of  the  abdomen  soon 
after  the  receipt  of  the  injury,  and  it  is  only  more  pronounced  when 
produced,  at  least  in  part,  by  sudden  and  severe  hemorrhage.  Pain 
is  a  very  unreliable  and  often  a  misleading  symptom,  as  it  may  be 
moderate  or  almost  completely  absent  soon  after  the  injury  has  been 
inflicted,  even  when  multiple  perforations  are  present.  The  pulse  at 
first  is  slow  and  compressible  in  all  cases,  and  nothing  characteristic 
m  its  qualities  is  observed  even  if  the  stomach  or  intestines  have 
been  wounded.  Hemorrhage  caused  by  wounds  of  any  of  the  large 
organs,  as  the  spleen,  liver,  or  kidneys,  gives  rise  to  progressive 
acute  anemia,  small  rapid  pulse,  cold  clammy  perspiration,  dilated 
pupils,  yawning,  vomiting,  and,  in  extreme  cases,  syncope  and  con- 
vulsions. The  local  symptoms  are  of  no  more  value  in  determining 
the  existence  of  visceral  injuries  in  penetrating  wounds  of  the  abdo- 
men than  are  the  general  symptoms  that  have  just  been  enumerated. 
External  hemorrhage  is  slight  or  entirely  absent,  unless  an  artery 
or  a  vein  in  the  abdominal  wall  has  been  injured.  The  bleeding 
from  visceral  wounds  gives  rise  to  accumulation  of  blood  in  the 
peritoneal  cavity — occult  or  internal  hemorrhage  ;  this  can  be  recog- 
nized by  physical  signs  that  denote  the  presence  of  fluid  in  the  free 
abdominal  cavity  and  by  general  symptoms  indicating  progressive 


DIAGNOSIS.  277 


anemia  :  increasing  pallor  of  the  face  and  of  the  visible  mucous 
membranes,  small  feeble  pulse,  superficial  sighing  respiration  and 
dilated  pupils.  Wounds  of  the  stomach  often  occasion  hemorrhao-e 
into  this  organ  and  hematemesis.  Blood  in  the  stools  seldom  fol- 
lows hemorrhage  into  the  bowels  from  intestinal  wounds  sufficiently 
early  to  be  of  any  diagnostic  value. 

Circumscribed  emph\-sema  in  the  tissues  around  the  track  made 
by  a  bullet  has  been  regarded  as  an  important  sign  of  the  existence 
of  intestinal  perforation.      This  s}-mptom  is  misleading  and  abso- 
lutely devoid  of  diagnostic  value,  as  this  condition   has  frequently 
been    observed   in  nonpenetrating  wounds  of    the  abdominal  wall 
resulting  from  the  entrance  of  air  into  the  loose  connective  tissue  or 
later  by  gas-formation  as  one  of  the  results  of  putrefactive  infection 
The  accumulation  of  an)-  considerable  quantit}^  of  gas  in  the  peri- 
toneal cavity  can  sometimes  be  recognized  by  the  disappearance  of 
the  normal  liver  dullness,  caused  by  the  presence   of  gas  between 
the  surface  of  the  liver  and  the  chest-wall.    This  condition  has  been 
sought  for  in  cases  of  perforating  wounds  of  the  abdomen  as  a  dia<^- 
nostic  sign,  and  if  found,  has  been  taken  as  a  sure  indication  of  the 
existence  of  visceral  wounds  of  the  gastro-intestinal   canal       This 
however,  is  not  always  the  case.    Adhesions  between  the  surface  of 
the  hver  and  chest- wall   may  have  existed  before  the  injury  was 
received,  or  the  amount  of  gas  present  may  be  insufficient  to  crive 
rise  to  this  symptom. 

Diagnosis.— If  a  gunshot  wound  has  penetrated  the  abdominal 
cavity  and  the  general  symptoms  and  local  signs  lead  us  to  suspect 
the  existence  of  dangerous  internal  hemorrhage,  no  time  should  be 
lost  in  further  efforts  to  make  an  accurate  anatomic  diagnosis    as 
sufficient  evidence  has  been  obtained  to  warrant  a  laparotomy'  for 
the  purpose  of  preventing  death  from  hemorrhage  bv  the  direct 
surgical  treatment  of  the  visceral  injuries.      If  no  such  urgent  indi- 
cation presents  itself,  it  is  desirable  that  the  existence  of  visceral 
lesions  demandmg  surgical  treatment  should  be  ascertained  before 
the  patient  is  subjected  to  the  additional  risk  incident  to  a  laparot- 
omy.   Since  a  simple  penetrating  wound  of  the  abdomen  is  an  injury 
from  which  the  majority  of  patients  recover  without  operative  treat- 
ment, and  since  visceral  wounds  of  the  gastro-intestinal   canal  are 
attended  by  such  frightful   mortality  without  surgical  interference 
the  practical   value  and  importance  of  a  correct  diagnosis  before 
deciding  upon  a  definite  plan  of  treatment  become  obvious.      It  is 
apparent  that  if  some  reliable  diagnostic  test  could  be  applied  in 
cases  of  penetrating  wounds  of  the  abdomen   that  would   indicate 
to  the  surgeon  the  presence  or  absence  of  visceral  lesions  of  the 
gastro-intestinal  canal,  the  indications  for  aggres.sive  or  conservative 
treatment  would  become  clear.      I  have  shown,  by  experiments  on 
animals,  and  later  by  clinical  experience  in  the  treatment  of  a  num- 
ber of  cases  of  gunshot  wounds  of  the  abdomen,  that  rectal   insuf- 
flation of  hydrogen  gas   can   be   relied   upon  in  demonstrating  the 


2^8  GUNSHOT    WOUNDS. 

existence  of  perforations  of  the  gastro-intestinal  canal  before  open- 
ing the  abdomen.  I  have  shown  conclusively  that  if  the  abdominal 
muscles  are  completely  relaxed  under  the  influence  of  a  general 
anesthetic,  hydrogen  gas  or  filtered  air  can,  under  safe  pressure,  be 
forced  from  the  anus  to  the  mouth  if  no  perforations  exist,  and  if 
such  are  present,  the  gas  will  escape  into  the  peritoneal  cavity, 
where  its  presence  can  be  readily  detected  by  the  physical  signs 
characteristic  of  a  free  tympanites  or  by  its  escape  through  the 
external  opening. 

Theoretic  objections  have  been  made  against  this  diagnostic  test 
on  the  ground  that  it  occasionally  fails  to  demonstrate  the  existence 
of  a  perforation,  and  that  it  is  instrumental  in  causing  fecal  extrava- 
sation. In  reply  to  this  I  must  say  that  it  has  never  failed  in  my 
hands  in  making,  by  its  aid,  a  correct  diagnosis,  and  the  fallacy  of 
the  second  objection  I  have  shown  repeatedly  by  experiments  on 
animals.  Hydrogen  gas  is  a  nontoxic  substance,  endowed  with 
valuable  inhibitory  antiseptic  properties,  and  is  absorbed  from  all 
the  larger  serous  cavities  and  connective  tissue  within  a  few  hours. 
Pure  zinc  and  sulphuric  acid  should  be  used  in  generating  the  gas, 
which  is  collected  in  a  rubber  balloon  holding  at  least  four  gallons. 
The  rubber  balloon  used  for  this  purpose  is  square  in  shape,  and  is 
connected  with  the  rectal  tip  by  means  of  a  rubber  tube  six  feet  in 
length  and  supplied  with  a  stop-cock  near  its  proximal  end.  In 
applying  the  test  an  assistant  presses  the  margin  of  the  anus  against 
the  rectal  tip,  so  as  to  prevent  the  escape  of  the  gas,  while  another 
assistant  forces  the  gas  along  the  intestinal  tube  by  pressing  or 
sitting  on  the  rubber  balloon.  The  gas  passes  through  the  ileocecal 
valve  under  a  pressure  of  two  and  a  half  pounds  to  the  square  inch, 
and  is  announced  by  a  distinct  gurgling  sound,  which  can  always  be 
distinctly  heard  by  applying  the  ear  or  the  stethoscope  over  that 
region.  If  the  rectum  or  colon  has  been  perforated,  the  gas  will 
not  reach  the  small  intestine,  but  will  escape  into  the  peritoneal 
cavity  under  less  pressure  than  is  required  in  rendering  the  ileo- 
cecal valve  incompetent.  As  soon  as  the  gas  reaches  a  perfora- 
tion large  enough  to  permit  its  escape  it  will  enter  the  peritoneal 
cavity  and  escape  through  the  external  wound,  if  this  has  been 
freely  laid  open  down  to  the  peritoneum.  If  the  external  wound  is 
in  a  location  that  points  to  injury  of  the  stomach,  this  organ  should 
be  insufflated  through  a  rubber  stomach-tube,  and  if  this  test  proves 
negative,  it  is  to  be  followed  by  rectal  insufflation.  It  is  impossible 
to  inflate  the  intestines  to  any  extent  from  the  stomach. 

Treatment. — The  propriety  of  surgical  interference  in  cases  of 
penetrating  gunshot  wounds  of  the  abdomen  will  depend  upon  one 
of  three  things  : 

1.  The  general  condition  of  the  patient. 

2.  Dangerous  internal  hemorrhage. 

3.  Wounds  of  the  stomach  or  intestines  large  enough  to  permit 
extravasation. 


PREPARATION    OF    PATIENT.  2/9 

If  the  patient  is  pulseless  and  presents  other  indications  of 
approaching  death,  operation  is  unjustifiable,  as  it  would  only  hasten 
the  end,  bring  reproach  upon  surgery,  and  undermine  the  confi- 
dence in  the  life-saving  value  of  the  operation  among  the  troops. 
Dangerous  internal  hemorrhage  that  will  come  to  the  notice  of 
militar}'  surgeons  in  gunshot  wounds  of  the  abdomen  will  be  cases 
in  which  the  vascular  organs  of  the  abdomen,  the  liver  and  the 
spleen,  or  some  of  the  larger  vessels  of  the  mesentery  or  omentum, 
have  been  injured.  Delay  in  such  cases  is  dangerous.  The  abdo- 
men should  be  opened  and  the  hemorrhage  arrested.  The  symp- 
toms are  apt  to  be  unusually  severe  if  the  hemorrhage  is  sudden, 
and  progressive  if  the  loss  of  blood  is  gradual.  In  the  last  case  it 
may  be  prudent  to  watch  the  case  for  some  time  for  more  pressing 
indications,  as  it  is  well  known  that  spontaneous  arrest  of  hemor- 
rhage may  occur,  and  large  quantities  of  aseptic  blood  are  removed 
from  the  peritoneal  cavity  in  a  short  time.  Visceral  lesions  of  the 
gastro-intestinal  canal  large  enough  to  permit  extravasation  are, 
with  very  few  exceptions,  mortal  wounds,  the  existence  of  which 
can  leave  no  doubt  in  the  mind  of  the  surgeon  that  prompt  resort 
to  abdominal  section  offers  the  only  chance  of  saving  life. 

Preparation  of  Patient. — A  patient  suffering  from  a  penetrating 
gunshot  wound  of  the  abdomen  should  be  properly  prepared  before 
he  is  subjected  to  laparotomy.  If  the  stomach  is  filled  with  food,  a 
salt-water  emetic  should  be  given,  for  the  purpose  of  emptying  its 
contents,  or,  better  still,  this  can  be  done  by  the  use  of  the  stomach 
siphon  tube.  The  rectum  and  colon  must  be  emptied  by  a  copious 
enema  of  warm  water,  to  which  may  be  added  a  tablespoonful  of 
common  salt.  The  unloading  of  the  gastro-intestinal  canal  will 
not  only  facilitate  the  operation,  but  will  have  a  favorable  influence 
in  securing  subsequent  rest  for  the  injured  part.  A  hypodermic 
injection  of  ^  of  a  grain  of  morphin  and  -^-^  of  a  grain  of  strychnin 
should  be  given  shortly  before  the  anesthetic  is  administered,  as 
these  remedies,  in  the  doses  specified,  assist  the  action  of  the  anes- 
thetic, secure  rest  for  the  intestines,  and  sustain  the  action  of  the 
heart.  If  the  patient  is  much  prostrated,  two  ounces  of  whisky 
diluted  with  four  ounces  of  warm  water  should  be  given  by  the 
rectum.  The  whole  abdomen  should  be  thoroughly  disinfected. 
Before  and  during  the  operation  the  use  of  external  dry  heat  will 
do  much  to  prevent  shock  and  to  aid  the  peripheral  circulation. 
Compresses,  towels,  and  several  gallons  of  warm  normal  solution 
of  .salt  must  be  provided.  The  operator  should  do  the  work 
with  as  little  assistance  and  as  few  instruments  as  possible,  as  the 
danger  of  infection  in  emergency  work  is  apt  to  be  proportionate 
to  the  number  of  assi.stants  and  instruments  employed.  Hands, 
instruments,  suturing  material,  in  fact  everything  that  is  to  be 
brought  in  contact  with  the  wound,  must  be  sterilized.  In  mili- 
tary surgery  silk  will  have  the  preference  over  catgut.  A  hospital 
tent  with  a  floor  will   be  an  admirable  operating  room  in  all  semi- 


280  GUNSHOT    WOUNDS. 

tropic  climates.  Anesthesia  should  be  commenced  with  chloroform 
until  the  patient  is  under  its  full  influence,  when  it  should  be  con- 
tinued with  ether. 

Incision. — In  the  majority  of  cases  the  median  incision  should 
be  made,  as  it  affords  advantages  that  give  it  the  preference.  It 
should  always  be  selected  in  cases  of  gunshot  wounds  of  the  stom- 
ach, and  where  the  wound  of  entrance  is  located  near  the  median 
line.  A  median  incision  affords  most  ready  access  in  the  treatment 
of  wounds  of  the  small  intestine.  If  the  insufflation  test  is  used,  it 
will  sometimes  prove  of  value  in  deciding  upon  the  location  of  the 
incision.  If  in  gunshot  wounds  of  the  upper  portion  of  the  abdo- 
men direct  inflation  of  the  stomach  through  an  elastic  tube  reveals 
the  existence  of  perforation  of  this  organ,  the  median  incision 
should  be  selected.  If  rectal  insufflation  yields  a  positive  result 
before  the  gas  has  passed  the  ileocecal  valve,  the  incision  should  be 
made  over  the  wounded  portion  of  the  colon,  which  is  usually  indi- 
cated by  the  course  of  the  bullet.  A  wound  in  the  transverse  colon 
can  be  found  and  dealt  with  most  effectually  through  a  high  median 
incision  ;  perforation  of  the  cecum  or  of  the  ascending  colon  calls 
for  a  lateral  incision  directly  over  the  wounded  organ,  while  a  lateral 
incision  on  the  left  side  is  indicated  if,  from  the  direction  of  the 
bullet,  it  is  evident  or  probable  that  the  colon  below  the  splenic 
flexure  is  the  seat  of  the  visceral  injury.  Laparotomy  performed 
for  the  arrest  of  hemorrhage  should  always  be  done  by  making  a 
long  median  incision,  which  will  afford  the  most  direct  access  to  the 
different  sources  of  hemorrhage.  Very  often  it  will  be  advisable  to 
make  the  incision  in  the  line  of  the  wound  of  entrance,  especially  in 
cases  in  which  a  lateral  incision  is  indicated  from  the  location  of  the 
wound,  from  the  course  of  the  bullet,  and  perhaps  from  the  results 
obtained  by  the  insufflation  test. 

Arrest  of  Hemorrhage. — In  opening  the  abdomen  in  the  treat- 
ment of  internal  hemorrhage  the  surgeon  undertakes  a  task  the 
gravity  of  which  it  is  impossible  to  foretell.  To  do  the  work  quietly 
and  well  he  must  be  perfectly  familiar  with  the  anatomy  of  the 
abdominal  organs  and  their  source  of  blood  supply,  and  must  have 
full  knowledge  of  all  hemostatic  resources,  the  indications  for  their 
selection,  and  the  details  of  application.  Profuse  intra-abdominal 
hemorrhage  resulting  from  penetrating  gunshot  wounds  of  the 
abdomen  is  more  frequently  of  parenchymatous  and  venous  than  of 
arterial  origin.  Wounds  of  the  liver,  spleen,  kidneys,  and  mesentery 
give  rise  to  profuse  and  often  fatal  hemorrhage.  After  opening  the 
peritoneal  cavity  it  is  often  very  difficult  to  find  the  bleeding  points, 
as  the  blood  accumulates  as  rapidly  as  it  is  sponged  out,  and  it 
becomes  necessary  to  resort  to  special  means  in  order  to  arrest  pro- 
fuse blee:ding  sufficiently  to  find  the  source  of  hemorrhage.  One 
of  two  means  should  be  employed:  (i)  Intra-abdominal  digital 
compression  of  the  aorta  ;  (2)  packing  the  abdominal  cavity  with  a 
number  of  large  sponges  or  gauze  compresses.     Intra-abdominal 


ARREST    OF    HEMORRHAGE.  28 1 

compression  of  the  aorta  below  the  diaphragm  can  readily  be  made 
by  an  assistant  introducing  his  hand  through  the  abdominal  incision, 
which  in  such  case  must  be  larger  than  under  ordinary  circum- 
stances. Compression  made  in  this  manner  will  promptly  arrest  the 
hemorrhage  from  any  of  the  abdominal  organs  for  a  sufficient  length 
of  time  to  enable  the  surgeon  to  find  the  source  of  hemorrhao^e,  and 
to  carry  out  the  necessary  treatment  for  its  permanent  arrest. 

Hemorrhage  from  a  perforated  kidney  may  demand  nephrectomy 
if  it  does  not  yield  to  tamponade.  If  the  tampon  is  used,  an  incision 
in  the  lumbar  region  must  be  made  for  the  removal  of  the  tampon, 
and  the  parietal  peritoneum  should  be  sutured,  so  as  to  exclude 
the  peritoneal  cavity  from  the  renal  wound.  Wounds  of  the  liver 
should  be  sutured  with  catgut,  cauterized  with  the  actual  cautery,  or 
tamponed  with  a  long  strip  of  iodoform  gauze  or  a  typical  Miku- 
licz tampon  ;  in  any  case  the  gauze  should  be  brought  out  of  the 
wound  and  utilized  as  a  drain. 

A  wound  of  the  spleen,  if  the  hemorrhage  does  not  yield  to 
ligation,  suturing,  or  tamponade,  necessitates  splenectomy.  Very 
troublesome  liemorrhage  is  often  met  in  wounds  of  the  mesentery. 
When  multiple  wounds  of  the  mesentery  and  visceral  wounds  of 
the  stomach  or  intestines  are  the  cause  of  hemorrhage,  it  is  a  good 
plan  to  pack  the  abdominal  cavity  with  a  number  of  large  sponges, 
napkins,  or  compresses  of  gauze,  to  each  of  which  a  long  strip  of 
gauze  is  securely  tied,  these  strips  being  allowed  to  hang  out  of 
the  wound  in  order  that  none  of  the  sponges  or  compresses  may 
be  lost  or  forgotten  in  the  abdominal  cavity  after  the  completion 
of  the  operation.  The  sponges  or  compresses  make  sufficient 
pressure  to  arrest  parenchymatous  oozing  as  well  as  venous  hem- 
orrhage if  they  are  placed  at  different  points  against  the  mesen- 
tery and  between  the  intestinal  coils.  The  sponges  are  removed 
one  by  one  from  below  upward,  and  the  bleeding  points  are  secured 
as  fast  as  they  are  uncovered.  The  ligation  of  mesenteric  and 
omental  vessels,  both  arteries  and  veins,  should  be  done  by  apply- 
ing the  ligature  en  masse.  A  round  needle  or  a  Thornton's  curved 
hemostatic  forceps  is  the  most  useful  instrument  for  this  purpose. 
Catgut,  as  a  rule,  should  not  be  relied  upon  in  tying  a  mesenteric 
vessel,  as  it  is  greatly  inferior  to  fine  silk. 

If  hemorrhage  is  profuse,  this  must  be  attended  to  before  any- 
thing is  done  in  the  way  of  finding  and  suturing  the  visceral 
wounds.  Troublesome  hemorrhage  from  a  large  visceral  wound  of 
the  stomach  or  intestines  is  best  controlled  by  hemming  the  margin 
of  the  wound  with  catgut  or  fine  silk.  In  hemorrhage  from  locali- 
ties not  accessible  to  ligation  and  not  amenable  to  tamponade,  pres- 
sure forceps  arc  applied  and  allowed  to  remain  for  from  twenty-four 
to  forty-eight  hours.  When  used  in  this  manner,  the  instrument 
must  be  long  enough  to  be  brought  out  of  the  wound,  and  should 
then  be  incorporated  in  the  dressing.  For  facilitating  the  finding 
and  removal  of  the  instrument  a  strip  of  gauze  is  tied  to  the  handle. 


282  GUNSHOT    WOUNDS. 

Search  for  Perforations. — A  number  of  cases  have  been  re- 
corded, and  I  am  sure  many  more  have  occurred,  in  which  laparot- 
omy was  performed,  one  or  more  perforations  sutured,  and  the 
postmortem  showed  that  a  perforation  was  overlooked,  death  result- 
ing from  extravasation  and  diffuse  septic  peritonitis.  Such  experi- 
ences are  by  no  means  limited  to  the  practice  of  novices,  but  have 
occurred  to  men  of  large  experience  and  in  well-equipped,  first-class 
hospitals.  The  handling  of  the  entire  length  of  the  gastro-intestinal 
canal  in  a  search  for  perforations  requires  time,  adds  to  the  shock  of 
the  injury  and  operation,  and  even  if  done  by  experts  and  with  the 
utmost  care,  a  perforation  may  escape  the  attention  of  the  operator 
and  become  the  sole  cause  of  death.  If  the  surgeon  adopts  this 
plan  of  detecting  the  perforations,  the  work  should  be  done  system- 
atically. The  ileocecal  region  is  the  best  landmark  in  beginning  the 
search.  From  here  the  small  intestine  may  be  traced  in  an  upward 
direction,  loop  after  loop  examined,  and  the  intestine  returned  as 
soon  as  examined  so  as  to  avoid  extensive  eventration,  which  adds 
greatly  to  the  danger  of  the  operation.  The  large  intestine  is  traced 
from  the  ileocecal  region  downward.  In  one  of  my  cases  a  perfora- 
tion of  the  rectum  was  found  low  down  in  the  pelvis,  and  certainly 
would  have  been  overlooked  if  I  had  not  used  the  inflation  test, 
which  promptly  revealed  not  only  its  existence,  but  also  its  exact 
location.  If  the  air-  or  gas-test  has  been  employed  with  a  positive 
result  before  the  abdomen  was  opened,  no  difficulty  will  be  experi- 
enced in  finding  the  first  opening.  If  the  stomach  was  inflated 
directly  through  an  elastic  tube  and  the  test  has  shown  the  presence 
of  a  perforation,  a  median  incision  should  be  made  from  the  tip  of 
the  ensiform  cartilage  to  the  umbilicus,  and  the  stomach  be  drawn 
forward  into  the  wound.  If  no  perforation  is  found  in  the  anterior 
wall,  the  insufflation  should  be  repeated,  and  the  escaping  air  or  gas 
will  direct  the  surgeon  to  the  perforation.  Through  this  perforation 
the  stomach  should  again  be  inflated  in  search  for  a  second  and 
possibly  a  third  perforation.  In  searching  for  intestinal  wounds 
by  the  aid  of  inflation  further  inflation  should  be  suspended  as  soon 
as  the  lowest  perforation  has  been  found.  If  possible,  the  perforated 
portion  of  the  intestine  should  now  be  brought  forward  into  the 
wound,  and,  after  emptying  the  intestine  below  the  perforation  as  far 
as  possible  of  its  contents,  including  the  gas  or  air,  the  bowel  should 
be  compressed  below  the  perforation  by  an  assistant,  and  the  intes- 
tine higher  up  be  inflated  through  the  wound.  As  a  matter  of 
course,  a  perfectly  aseptic  glass  tube  should  be  inserted  into  the 
rubber  tube  in  place  of  the  rectal  tip.  The  inflation  should  now 
be  carried  as  far  as  the  second  opening,  after  which  the  first  per- 
foration should  be  sutured,  and,  after  disinfecting  and  emptying  the 
intervening  portion  of  its  gas,  the  intestine  should  be  replaced  in 
the  abdominal  cavity.  Further  inflation  is  now  made  through  the 
second  opening ;  and  if  a  third  one  is  found,  the  second  is  sutured, 
and  so  on  until  the  entire  intestinal  canal  has  been  thoroughly  sub- 


SUTURING    THE    PERFORATIONS.  283 

jected  to  the  test.  By  following  this  plan  extensive  eventration 
is  rendered  superfluous  and  the  overlooking  of  a  perforation  is 
made  impossible  ;  likewise,  the  objection  to  the  test  that  reduction 
of  the  intestines,  owing  to  distention  with  gas  or  air,  is  difficult,  is 
overcome  if  the  intervening  sections  between  the  perforations  are 
emptied  of  their  contents  before  suturing  the  wound. 

Suturing  the  Perforations. — The  materials  for  suturing  are  an 
ordinary  sewing  needle  and  fine  aseptic  silk.  Catgut  should  be  dis- 
pensed with  in  all  intestinal  work.  Trimming  the  margins  of  the 
visceral  wounds  is  not  only  superfluous,  but  absolutely  harmful,  as 
it  requires  a  useless  expenditure  of  time  and  may  become  an  addi- 
tional source  of  hemorrhage.  The  same  can  be  said  of  the  Czerny- 
Lembert  suture.  All  that  is  required  in  the  treatment  of  a  visceral 
wound  of  the  stomach  and  intestines  is  to  turn  the  margins  of  the 
wound  inward  and  bring  into  apposition  healthy  serous  surfaces  by 
the  continuous  or  b}' interrupted  seromuscular  sutures,  which  should 
alwa}'s  be  made  to  include  the  fibers  of  Halsted's  submucosa._  From 
four  to  six  sutures  to  an  mch  will  suffice.  If  possible,  wounds  of 
the  stomach  should  be  sutured  in  the  direction  of  the  blood-vessels, 
and  transverse  suturing  of  the  intestine  is  necessary  for  the  purpose 
of  preventing  constriction  of  the  lumen.  Defects  an  inch  and  a 
half  in  length  on  the  conv^ex  side  can  be  closed  in  this  manner  with- 
out fear  of  causing  intestinal  obstruction,  while  much  smaller  defects 
on  the  mesenteric  side  usually  necessitate  a  resection,  not  only 
because  the  vascular  supply  in  the  corresponding  portion  of  the 
intestine  would  be  inadequate,  but  also  because  a  sufficiently  sharp 
flexion  might  be  produced  at  the  seat  of  suturing,  to  become  the 
immediate  mechanical  cause  of  intestinal  obstruction. 

Enterectomy. — Enterectomy  is  often  indicated  in  cases  of  double 
perforation  and  in  marginal  wounds  of  the  mesenteric  border.  If  in 
cases  of  multiple  perforations  it  should  become  necessary  to  make  a 
double  enterectomy,  and  the  intervening  portion  of  the  small  intes- 
tine is  not  more  than  two  or  three  feet  in  length,  it  is  best  to  resect 
the  same,  as  the  immediate  effect  of  the  single  operation  will  be  less 
severe  than  that  of  a  double  resection  with  a  corresponding  double 
enterorrhaphy.  After  resection,  the  continuit\'  of  the  intestinal  canal 
should  always  be  restored  by  a  circular  enterorrhaphy,  using  for 
this  purpose  the  Czerny-Lembert  suture.  Strips  of  sterile  gauze  are 
preferable  to  clamps  or  Murphy's  button  in  preventing  extravasation 
during  the  operation.  The  gauze  strip  is  passed  through  a  small 
buttonhole  made  with  hemostatic  forceps  in  the  mesentery  near  the 
intestine,  and  tied  with  sufficient  firmness  to  prevent  escape  of 
intestinal  contents. 

Irrigation  of  the  Abdominal  Cavity. — This  is  necessary  only  if 
fecal  extravasation  or  escajjc  of  stomach-contents  has  taken  place, 
an  accident  that,  if  it  has  not  occurred  before  the  abdomen  was 
opened,  should  be  carefully  avoided  during  the  manipulation  of  the 
wounded   intestines.       Flushing   the   peritoneal    cavity   with   warm 


284  GUNSHOT   WOUNDS. 

sterilized  water  or  normal  salt  solution  not  only  clears  it  of  infec- 
tious material,  but  acts  at  the  same  time  as  a  stimulant  to  the  flag- 
ging circulation.  The  current  must  be  sufficiently  strong  not  only 
to  fill  the  peritoneal  cavity  quickly,  but  to  flusJi  it  out. 

After  completion  of  the  irrigation  the  patient  is  placed  on  his 
side,  and  in  this  position  the  fluid  contents  of  the  abdominal  cavity 
are  poured  out.  The  cavity  is  then  rapidly  dried  with  large  sponges 
wrung  out  of  a  weak  sublimate  solution  (i  :  10,000)  or  Thiersch's 
solution.  Some  surgeons  have  practically  abandoned  flushing  of 
the  abdominal  cavity,  and  rely  almost  exclusively  on  sponging  in 
removing  pus  and  extravasated  fecal  material  ;  others  are  partial  to 
leaving  the  physiologic  solution  of  salt  in  the  cavity,  paying  no 
attention  to  the  peritoneal  toilet  practised  with  conscientious  care 
by  all  surgeons  only  a  few  years  ago. 

Drainage. — To  drain  or  not  to  drain  is  the  all-absorbing  topic 
among  surgeons  whose  time  and  attention  are  engaged  largely  in 
abdominal  work.  I  wish  to  place  myself  on  record  as  being  a  strong 
advocate  of  drainage  in  all  cases  of  abdominal  surgery  in  which  we 
have  reason  to  believe  that  contamination  of  the  peritoneal  cavity 
has  taken  place  by  extravasation  of  contents  of  the  gastro-intestinal 
canal  or  by  pus.  In  gunshot  wounds  of  the  abdomen  complicated 
by  visceral  injury  the  probability  that  infection  has  occurred  must 
not  be  lost  sight  of,  and  the  only  safe  course  to  pursue  under  such 
circumstances  is  to  drain  when  you  are  in  doubt.  Cases  that  require 
irrigation  should  always  be  drained.  Other  indications  for  drainage 
are  visceral  wounds  of  the  liver  and  pancreas  and  the  existence  of 
parenchymatous  hemorrhage  that  can  not  be  remedied  by  any  of 
the  different  hemostatic  measures.  A  glass  drain  reaching  to  the 
bottom  of  the  pelvis,  loosely  packed  with  a  strip  of  iodoform  gauze, 
answers  an  excellent  purpose.  Occasionally  multiple  drains  are 
indicated.  The  Mikulicz  drain  is  to  be  depended  upon  in  arresting 
troublesome  surface  oozing.  Drainage  must  be  suspended  at  once, 
or  gradually,  with  the  cessation  of  the  primary  wound  secretion. 

Suturing  of  External  Incision. — Incisions  through  the  median 
line  are  rapidly  closed  by  one  row  of  silk  or  silkworm-gut  sutures, 
which  are  placed  close  together  and  include  all  the  tissues  of  the 
margins  of  the  wound.  Incisions  made  in  any  other  place  are  to  be 
closed  by  buried  catgut  sutures  uniting  the  peritoneum  and  muscu- 
lar layer  separately,  and  a  superficial  row  of  silkworm-gut  sutures 
including  all  the  tissues  except  the  peritoneum.  A  large  hygro- 
scopic compress  composed  of  sterile  gauze  and  absorbent  cotton, 
held  in  place  by  broad  strips  of  adhesive  plaster,  constitutes  the 
proper  dressing.  The  sutures  are  removed  at  the  end  of  the  second 
week,  and  the  patient  must  not  be  allowed  to  leave  the  bed  before 
the  expiration  of  the  fourth  week.  Four  weeks  in  bed  and  the 
wearing  of  a  well-fitting  abdominal  support  for  from  three  to  six 
months  are  the  most  reliable  precautions  against  the  occurrence  of 
a  postoperative  ventral  hernia.      The  drainage  opening  should  be 


GUNSHOT   WOUNDS    OF    THE    SPINE.  285 

closed  with  secondary  sutures,  inserted  at  the  time  of  operation,  as 
soon  as  the  drain  is  removed,  otherwise  a  ventral  hernia  will  be 
almost  sure  to  develop  in  the  scar  at  the  former  site  of  the  drainage 
tube. 

After-treatment. — Absolute  rest  must  be  strictly  enforced. 
Opiates  must  be  given  in  doses  sufficiently  large  to  quiet  the  peri- 
staltic action  of  the  intestines.  Stimulants  must  be  used  to  counter- 
act the  effect  of  shock  and  to  restore  the  vigor  of  the  enfeebled 
peripheral  circulation.  Strict  dieting  must  be  observed  for  at  least 
forty-eight  hours.  During  this  time  a  mixture  of  brandy  and  iced 
water,  in  small  doses  frequently  repeated,  or  iced  champagne,  is 
agreeable  to  the  patient,  as  it  quenches  thirst,  relieves  nausea,  and 
exerts  a  favorable  influence  upon  the  circulation.  If  more  active 
stimulation  is  called  for  to  overcome  shock  and  the  effects  of 
hemorrhage,  whisky,  strychnin,  ether,  musk,  or  camphor  can  be 
injected  subcutaneously  or  by  the  rectum,  while  the  peripheral  cir- 
culation is  restored  by  applying  dry  heat  to  the  extremities  and 
trunk.  The  subcutaneous  infusion  of  one  or  two  pints  of  normal 
salt  solution  is  an  excellent  restorative  and  of  special  therapeutic 
efficiency  in  cases  where  the  vital  forces  are  depressed  and  life  is  in 
danger  from  the  effects  of  hemorrhage. 

Should  symptoms  of  peritonitis  set  in,  a  brisk  saline  cathartic 
should  be  given  at  the  end  of  forty-eight  hours,  as  at  this  time  the 
intestinal  wounds  will  have  become  united  sufficiently  to  resist  the 
peristalsis  provoked  by  the  cathartic,  while  the  removal  of  intestinal 
contents  and  the  absorption  of  septic  material  from  the  peritoneal 
cavity  thus  attained  are  not  only  the  most  efficient  means  of  avert- 
ing a  fatal  disease,  but  also  of  placing  the  wounds  in  the  most  favor- 
able condition  for  rapid  repair.  Instead  of  giving  the  saline  cathartic 
in  one  dose,  it  is  better  to  give  it  in  small  doses,  repeated' every 
half-hour.  Sulphate  of  magnesia  in  dram  doses  repeated  every 
half-hour  acts  like  a  charm  and  should  be  the  cathartic  of  choice. 
Reopening  of  the  wound  and  secondary  flushing  have  done  little  in 
arresting  or  limiting  septic  peritonitis.  If  the  case  progresses  favor- 
ably, liquid  food  by  the  stomach  can  be  allowed  at  the  end  of  the 
second  day,  and  light  solid  food  at  the  end  of  the  first  week.  Under 
ordinary  circumstances  no  effort  is  made  to  move  the  bowels  until 
the  end  of  the  third  or  fourth  day.  If  early  feeding  becomes  neces- 
saiy  in  marasmic  or  exsanguinated  patients,  this  can  be  done  by 
rectal  alimentation. 

GUNSHOT  WOUNDS  OF  THE  SPINE. 
All  cases  of  gunshot  wounds  of  the  spine  in  which  the  cord 
was  seriously  damaged  that  came  under  my  ob.servation  in  Cuba 
during  the  war  with  Spain  either  died  or  were  the  subjects  of  fatal 
complications  when  last  seen.  The  immediate  cause  of  death  in 
.such  ca.ses  was  either  a  .septic  leptomeningitis  or  sepsis  and  exhaus- 
tion from  decubitus.      Death  from  the  former  cause  occurred  early, 


286 


GUNSHOT    WOUNDS. 


in  consequence  of  infection  of  the  wound  and  extension  of  the 
inflammation  at  the  seat  of  the  visceral  injury  along  the  meninges 
and  surface  of  the  cord. 

Case  i. — The  first  case  of  this  kind  I  saw  was  at  El  Caney,  a  few  days  after  the 
little  city  was  stormed  by  our  troops.  The  patient  was  a  Spanish  prisoner.  I  found  him 
lying  helpless  on  the  bare  stone  floor  of  the  old  church.  The  bullet  had  entered  over  the 
center  of  the  spine,  at  the  junction  of  the  dorsal  with  the  lumbar  vertebrae,  its  course 
being  apparently  directly  forward.  There  was  no  wound  of  exit.  Complete  paraplegia 
was  present  below  the  seat  of  injury.  The  bladder  was  distended,  reaching  nearly  the 
level  of  the  umbilicus,  and  there  was  incontinence  of  urine.  The  neck,  the  trunk  above 
the  wound,  and  the  upper  extremities  were  rigid.  There  was  high  fever,  and  the  pulse 
was  rapid  and  small.  The  countenance  was  extremely  pale  and  expressive  of  great  suf- 
fering. The  wound  was  protected  by  a  small  dirty  dressing  and  was  suppurating.  I 
doubt  not  that  relief  by  death  came  to  him  in  less  than  twenty-four  hours  after  I  saw  him. 

Wounds  of  the  spine  without  injury  to  the  cord  were  frequently 
attended  by  temporary  paralysis,  varying  greatly  in  degree  and 
duration. 

Case  2.— George  Kelly,  Company  C,  Seventeenth  Infantry,  was  shot  July  ist,  while 
lying  in  a  prone  position.     The  bullet,  which  was  fired  from  a  blockhouse  on  the  summit 

of  a  hill,  at  a  distance  of  about  600  yards,  en- 
tered the  body  at  a  point  a  little  below  the 
margin  and  at  the  middle  of  the  right  ilium, 
emerging  from  the  opposite  side  about  three 
inches  below  the  crest  of  the  left  ilium  (Fig. 
169).  The  patient  asserted  that  he  suffered 
intense  pain  immediately  after  he  was  shot,  and 
that  in  a  little  more  than  a  week  after  the  acci- 
dent he  was  free  from  pain  except  when  he 
attempted  to  walk.  The  pain  thus  caused  he 
referred  to  the  sacrococcygeal  joint.  The 
wounds  healed,  and  the  absence  of  paralysis 
was  the  best  evidence  that  the  contents  of  the 
spinal  canal  escaped  injury,  although  the  bullet 
must  have  passed  through  the  first  sacral  ver- 
tebra from  side  to  side. 

Case  3. — John  Robinson,  Company  C, 
Twenty-fourth  Infantry.  The  bullet  entered 
the  supraspinous  fossa  of  the  left  scapula,  and 
escaped  from  the  right  lumbar  region,  having 
perforated,  in  its  long  course,  the  lung,  spinal 
cord,  liver,  and  diaphragm.  The  wounds 
healed  in  ten  days.  Expectoration  was  bloody  and  there  was  complete  paraplegia. 
Beginning  extensive  decubitus  over  sacrum  and  spinous  processes  occurred. 

Case  4. — Otto  Derr,  Company  A,  Twenty-first  Infantry,  was  wounded  July  2d.  The 
bullet  passed  through  the  chest,  from  side  to  side,  from  the  postaxillary  line  on  the  right 
side  to  a  corresponding  point  on  the  opposite  side,  on  a  level  with  the  seventh  intercostal 
space.  There  was  complete  paralysis  of  motion  and  sensation  below  the  seat  of  the  spinal 
injury.  The  wounds  healed  by  primary  intention,  but  life  was  threatened  at  the  time 
from  a  smouldering  septic  decubitus. 

Case  5. — Lewis  Carlisle,  Company  K,  Seventy-first  New  York  Volunteers,  was  hit 
in  the  back  by  a  shrapnel  on  a  level  with  the  third  lumbar  vertebra,  shattering  the 
spinous  and  left  lateral  process  of  the  same.  The  missile  was  removed  as  soon  as  the 
patient  reached  the  division  hospital.  As  profuse  suppuration  set  in  and  continued,  the 
patient  was  anesthetized  July  1 8th,  and  a  number  of  fragments  of  bone  were  removed. 
A  large  abscess  cavity  in  the  right  lumbar  region  communicated  with  the  wound.  This 
cavity  was  drained  by  making  a  counteropening  in  line  with  Simon's  lumbar  incision. 
Impaired  sensation  in  the  right  leg  was  the  most  important  focal  symptom  in  this  case. 

Case  6. — Charles  Reardon,  Company  C,  Sixteenth  Infantry,  was  wounded  by  a 
fragment  of  shrapnel  that  struck  him  while  lying  down,  with  his  shoulders  raised, 
ready  to  fire.  The  wound  was  directlv  over  the  center  of  the  spine,  on  a  level  with  the 
fourth  dorsal  vertebra;      The  missile  evidently  perforated  the  spinal  canal  and  injured  its 


-Gunshot  wound  of  the 
spine. 


GUNSHOT    WOUNDS    OF    THE    SPINE.  287 

contents.  The  foreign  body  remained  embedded  in  the  tissues  and  its  location  was  not 
determined.  Paraplegia  was  complete  below  the  level  of  the  umbilicus.  On  July  i8th 
the  patient  was  still  alive,  but  an  extensive  moist  decubitus  became  the  direct  cause  of 
death  a  few  days  later. 

The  following-  cases  came  to  my  attention  in  the  military  hos- 
pitals at  Constantinople  during  the  Greco-Turkish  war  : 

Case  T.  — Gunshot  Fracture  of  the  Spinous  Process  at  the  Junction  of  the  Dorsal  with 
the  Lumbar  VcrtebrcB. — Paraplegia  was  complete  immediately  after  receipt  of  injury. 
Paralysis  remained  until  laminectomy  was  performed.  Operation  was  followed  by  prompt 
improvement.  Patient  was  subsequently  able  to  walk  with  the  aid  of  crutches.  Depres- 
sion of  the  fractured  vertebral  arch  was  found  to  be  the  cause  of  the  paralysis. 

Case  8. —  Gunshot  Injury  of  Spine  in  the  Lumbar  Region. — Paralysis  was  complete 
from  the  beginning.  The  wound  healed,  but  the  bullet  remained  in  the  tissues.  The 
cord  had  probably  been  crushed  by  the  bullet  or  fragments. 

In  gunshot  injuries  of  the  spine  the  first  duty  of  the  surgeon  is 
to  protect  the  wound  against  infection  by  the  early  use  of  the  anti- 
septic first-aid  dressing.  Patients  thus  injured  must  receive  more 
than  ordinaiy  care  during  their  transportation  to  the  field-hospital, 
to  prevent  additional  injury  to  the  cord  by  displacement  of  the  frag- 
ments. No  exploration  or  operation  is  justifiable  until  the  patient 
has  been  conveyed  to  a  place  where  asepsis  can  be  assured.  If  the 
direction  of  the  bullet  and  the  symptoms  presented  leave  no  reason- 
able doubt  of  the  crushing  of  the  cord  by  the  bullet  or  fragments, 
conservatism  is  the  most  humane  course  to  pursue.  Aseptic  cath- 
eterization and  proph)'lactic  measures  against  decubitus  constitute 
the  most  important  part  of  the  treatment.  One  of  the  best  local 
applications  to  parts  threatened  by  gangrene  is  the  unguentum 
plumbi  tannici.  If  injury  to  the  cord  can  be  excluded  and 
paralysis  presents  itself  at  once  and  is  complete  immediately  on 
receipt  of  the  injury,  it  is  caused  either  by  concussion  or  by  com- 
pression, and  operative  intervention  must  be  postponed  until  a 
differential  diagnosis  can  be  made  by  the  duration  and  extent  of  the 
paralysis.  If  symptoms  of  improvement  manifest  themselves  in  the 
course  of  a  week  or  two,  the  suspicion  of  concussion  is  confirmed, 
and  a  conservative  course  of  treatment  is  to  be  followed  ;  if  the 
reverse  is  the  case,  the  propriety  of  cutting  down  upon  the  seat  of 
injury  must  be  seriously  considered,  and  the  cause  of  compression 
must  be  searched  for  and,  if  found,  removed. 

Dr.  Prewitt,  of  St.  Louis,  removed  a  bullet  from  the  spinal  canal 
in  the  cervical  region,  and  had  the  satisfaction  of  seeing  motion  and 
sensation  return  promptly  after  the  operation.  Secondary  lamin- 
ectomy not  infrequently  yields  .satisfactory  results  if  the  cause  of  the 
paralysis  consists  of  a  depressed  arch,  as  was  the  case  in  case  7,  or 
of  displaced  fragments.  Late  and  gradually  increasing  paralysis 
results  from  hemorrhage  into  the  spinal  canal  or  inflammatory 
changes  at  the  seat  of  fracture.  In  the  former  case  operative  inter- 
vention is  superfluous,  and  in  the  latter  case  it  is  powerless  to  re- 
store the  function  of  the  compres.scd  di.seased  cord.  If  any  of  the 
bodies  of  the  vertebra;  have  been  comminuted,  immobilization   of 


288  GUNSHOT    WOUNDS. 

the  spine,  first  by  rest  in  bed  and  later  by  an  appropriate  me- 
chanical support,  is  necessary  in  preventing  aggravation  at  the  seat 
of  fracture  and  in  placing  the  injured  parts  in  the  best  condition 
for  a  speedy  and  satisfactory  repair. 

GUNSHOT  WOUNDS  OF  THE  NERVES. 

Injury  of  any  of  the  large  nerve -trunks  in  gunshot  wounds 
always  constitutes  a  serious  complication,  as,  owing  to  the  nature 
of  the  wound,  union  without  surgical  intervention  seldom  takes 
place.  The  nerve  wound  may  also  furnish  one  of  the  indications 
for  amputation  if  associated  with  gunshot  fractures  of  the  lower 
extremities.  If  the  course  of  the  bullet  indicates  the  probable  ex- 
istence of  a  nerve  wound,  it  becomes  necessary  on  the  part  of  the 
surgeon  to  examine  closely  into  the  degree  of  loss  of  nerve  function 
below  the  seat  of  injury,  and  consequently  he  tests  the  functional 
disturbances  of  sensation  as  well  as  of  motion.     Nerve  contusion 


Fig.  170. — Nerve  suture  :  a.  Direct ;  b,  perineurotic  ;  c,  paraneurotic  ;  d,  e,  neuroplasty. 

will  be  met  less  frequently  in  wounds  made  by  the  small-caliber 
than  by  the  large-caliber  bullet,  while  the  cases  of  partial  or  com- 
plete nerve  division  will  be  of  more  frequent  occurrence.  If  a 
nerve  is  completely  divided,  the  gap  between  the  ends,  by  destruc- 
tion of  tissue  and  displacement  of  the  nerve-ends,  is  so  great  that 
restoration  of  continuity  without  surgical  interference  can  hardly 
be  expected.  Partial  section  of  a  nerve  by  a  bullet  leaves  a  wound 
compatible  with  healing  and  restoration  of  function.  Concussion 
and  contusion  of  nerves  by  the  passage  of  a  bullet  in  close  proximity 
often  result  in  complete  sudden  paralysis,  but  function  is  restored 
in  the  course  of  from  a  few  days  to  several  weeks  or  months. 

Primary  nerve  suture  is  only  to  be  thought  of  if  the  injured 
nerve  is  readily  accessible.  The  nerve-ends  should  be  cut  squarely 
with  a  very  sharp  knife  or  scissors,  and  the  clean-cut  surfaces 
united  by  at  least  three  direct  nerve  sutures.  An  ordinary  sew- 
ing needle  armed  with  fine  catgut  may  be  used  for  this  purpose. 


GUNSHOT    WOUNDS    OF    THE    NERVES.  289 

The  mechanical  union  can  and  should  be  strengthened  by  at  least 
two  paraneural  sutures,  and  tension  be  avoided  either  by  nerve 
stretching  or  position,  or  a  combination  of  both  of  these  measures 
in  cases  in  which  the  loss  of  substance  is  extensive.  It  is  always 
well  to  suture  some  of  the  deep  tissues  over  the  united  portion  of 
the  nerve  by  two  or  more  buried  catgut  sutures,  in  order  to  supply 
the  nerve  wound  with  a  bed  of  vascular  tissue. 

The  most  serious  cases  of  nerve  injury  are  those  in  which  an 
adjacent  large  blood-vessel  has  been  wounded  at  the  same  time.  If 
at  the  base  of  any  of  the  extremities  a  gunshot  fracture  is  compli- 
cated by  a  wound  of  the  principal  blood-vessel  and  nerve  or  nerves, 
the  indications  for  amputation  are  clear,  as  gangrene  could  not  be 
prevented  in  such  cases  by  the  most  careful  treatment  of  the  frac- 
tured bone  and  vessel  and  nerve  wounds.  In  the  absence  of  a 
fracture  it  is  in  such  cases  that  occasionally  the  patient  recovers  with 
a  traumatic  aneurysm  and  a  paralyzed  limb.  Two  cases  of  this  kind 
have  recently  come  under  my  observation. 

Case  i. — A  robust  man,  thirty-five  years  of  age,  presented  himself  for  treatment  in 
the  clinic  of  Rush  Medical  College  during  the  winter  semester,  1899.  Six  months  before 
he  was  admitted  he  was  shot  at  close  range  through  the  arm,  at  about  the  junction  of  the 
middle  with  the  upper  third  on  the  inner  side,  the  bullet  passing  in  an  anteroposterior 
direction.  Hemonhage,  quite  profuse  and  evidently  arterial,  was  arrested  by  the  surgeon 
who  was  called.  Complete  loss  of  motion  and  sensation  occurred  in  the  parts  of  the  fore- 
arm supplied  by  the  median  and  ulnar  nerves.  A  swelling  the  size  of  a  small  orange 
developed  in  the  track  of  the  bullet  almost  immediately  after  the  injury  was  received.  I 
found  marked  atrophy  of  the  muscles  of  the  forearm,  and  a  pulsating  swelling  in  the  line 
of  the  brachial  artery  and  on  a  level  with  the  scars  following  healing  of  the  wound. 
Auscultation  revealed  a  distinct  bruit,  loudest  over  the  swelling.  The  radial  pulse  was 
decidedly  smaller  than  on  the  opposite  side.  Superficial  circulation  was  feeble,  and  the 
skin  was  quite  cyanotic  below  the  aneurysm.  Sensation  and  motion  in  the  territories  sup- 
plied by  the  median  and  ulnar  nerves  were  completely  abolished.  The  musculospiral 
nerve  was  intact.  Over  the  upper  segment  of  the  aneurysm  I  could  distinctly  feel  two 
painful  and  exquisitely  tender  bulbous  enlargements,  which  indicated  the  location  of  the 
proximal  end  of  the  divided  nerves. 

It  was  my  intention  when  I  first  presented  the  cnse  to  the  class  to  perfonn  a  radical 
operation,  consisting  in  secondary  nerve  suturing  and  excision  of  the  traumatic  aneurysm. 
On  .second  thought  it  became  clear  to  me  that  such  a  procedure  would  almost  inevitably 
be  followed  by  gangrene  of  the  forearm,  as  the  paralysis  and  sudden  and  complete  inter- 
ruption of  the  arterial  blood  supply  would  be  almost  certain  to  suspend  nutrition.  I  then 
planned  another  course,  which  consisted  in  attempting  secondary  nerve  suture  without 
interfering  with  the  aneurysmal  sac.  The  operation  proved  a  very  difficult  and  tedious 
one,  as  ilie  nerve-ends  made  up  a  part  of  the  wall  of  the  traumatic  aneurysm.  In  liber- 
ating the  nerve-ends  I  left  a  jjart  of  them  attached  to  the  sac,  vivified  freely,  and  placed 
the  sutured  nerves  in  a  position  that  would  best  facilitate  the  subse<|uent  removal  of  the 
aneurysm  by  excision.  The  arm  was  immobilized  and  kej)t  in  an  elevated  position  for 
twenty-four  hours.  The  operation  wound  healed  by  ])rimary  intentie)n,  and  distinct  evi- 
dences of  return  of  nerve  function  Ijecame  apparent  in  less  than  two  weeks  after  the  opera- 
tion. The  operation  did  not  interfere  in  any  way  with  the  blood  sui)])ly  to  the  paralyzed 
arm,  and  it  is  my  intention,  after  innervation  has  been  fully  restored,  to  excise  the  aneurysm, 
and  with  the  return  of  nerve  function  the  second  .step  of  the  operation  can  be  performed 
with  little  or  no  risk  of  incurring  gangrene. 

Cask  2. — This  case  I  had  an  opjiortunity  of  examining  at  the  Presidio,  San  Fran- 
cesco, July  9,  1899,  through  the  courtesy  of  the  Commander  of  the  Military  Hospital, 
Major  A.  C.  Oirard,  U.S.A.  The  jjatient  was  a  soldier  who  had  recently  returned  from 
Manila.  He  was  wounded  in  the  battle  at  Malabon.  The  bullet  passed  oblitjuely  from 
behind  forward  and  outward.  It  entered  a  little  below  the  level  of  the  shoulder-joint,  on 
the  axillary  sifle  of  the  right  sca|)ula,  and  emerged  anteriorly  at  the  axillary  base  and 
inner  border  of  the  jjecloralis  major  muscle.  A  swelling  apjiearcd  over  the  first  portion 
of  the  brachial  artery  almost  inunediateiy  after  the  injury  was  received.  Hemorrhage 
»9 


290 


GUNSHOT    WOUNDS. 


from  wounds  of  entrance  and  of  exit  was  slight.  Wounds  healed  under  first-aid  dressing 
by  primary  intention.  Paralysis  was  complete  immediately  after  he  was  shot.  There  was 
slight  atrophy  of  the  forearm.  A  swelling  not  lai-ger  than  a  walnut  appeared  directly 
over  the  brachial  artery,  in  the  track  made  by  the  bullet.  Patient  was  satisfied  that  this 
swelling  had  been  gradually  diminishing  in  size.  Pulsation  was  slight,  and  bruit  feeble. 
On  palpation  the  aneurysmal  swelling  was  found  to  be  quite  hard,  imparting  the  sensation 
indicative  of  consolidation  of  at  least  parts  of  its  contents.  Sensation  was  fully  restored 
in  the  parts  supplied  by  the  median  nerve.  The  ulnar  side  of  the  ring-finger  was  very 
sensitive  to  touch,  and  the  little  finger  was  anesthetic. 

It  was  evident  that  in  this  case  the  paralysis  of  the  median  nerve  was  caused  by 
contusion. 

The  ulnar  nerve  was  injured  more  severely  and  was  probably  partly  cut.  The  func- 
tion in  the  branch  that  supplies  the  ulnar  side  of  the  ring-finger  was  restored,  and 
undoubtedly  represented  the  uncut  part  of  the  nerve.  In  view  of  the  progressive  im- 
provement of  innervation  and  the  gradual  diminution  in  the  size  of  the  aneurysm,  it  was 
advised  to  postpone  operative  treatment,  if  such  would  become  necessary,  for  at  least 
four  or  five  months,  as  by  doing  so  nothing  would  be  lost  and  much  might  be  avoided 
and  gained. 

GUNSHOT  WOUNDS  OF  ARTERIES. 
Death  from  hemorrhage  from  arterial  Avounds  and  aneurysms 
will  be  of  more  frequent  occurrence  in  military  practice  since  the 
introduction  of  the  small-caliber  weapon.  The  small-caliber  bullet 
inflicts  wounds  more  closely  resembling  incised  wounds  than  those 
made  by  the  large-caliber  leaden  bullet ;  consequently  wounds  that 
are  more  prone  to  hemorrhage  and  aneurysm  formation.  On  the 
other  hand,  secondary  hemorrhage  will  be  less  frequently  observed, 
as  wounds  made  by  the  small-bore  bullet  are  more  nearly  aseptic 
than  the  wounds  inflicted  by  the  old-fashioned  leaden  bullet.  More- 
over, our  means  for  maintaining  their  aseptic  condition  are  such  that 
infection  and  suppuration  can  be  more  effectually  prevented. 

Case  i. — The  first  case  of  traumatic  aneurysm  following  a  gunshot  wound  during  the 
Spanish-American  war  I  saw  in  the  General  Hospital  at  Siboney.  It  was  a  case  of  gun- 
shot wound  of  the  subclavian  artery.  The  swelling  appeared  immediately  upon  the 
receipt  of  the  injury,  and  in  a  very  short  time  attained  the  size  of  a  large  orange.  The 
wound  healed  by  primary  intention.  The  supraclavicular  swelling  presented  all  the 
clinical  aspects  of  a  traumatic  aneurysm — pulsation  and  bruit.  The  patient  was  sent  to 
New  York  on  one  of  the  first  transports,  and  was  transferred  to  one  of  the  hospitals  in 
Brooklyn.  Two  months  later  an  attempt  was  made  to  ligate  the  subclavian  artery,  but 
the  patient  died  on  the  table  from  hemorrhage  before  the  completion  of  the  operation. 

Case  2. — Captain  Mosher,  Company  G,  Twenty-second  Infantry,  received  a  bullet 
wound  July  1st  during  the  advance  on  Santiago.  Those  who  saw  the  patient  first  assert 
that  the  hemorrhage  was  severe  and  that  the  patient  lost  consciousness.  He  was  removed 
to  the  First  Division  Hospital,  and  transferred.  July  loth,  to  the  general  hospital.  The 
following  day  he  was  brought  on  board  the  Relief.  I  examined  the  patient  at  the  front 
five  days  after  battle,  and  confirmed  the  diagnosis  made  by  the  attending  surgeons,  who 
had  correctly  interpreted  the  anatomic  nature  of  the  aneurysm.  The  wounds  healed  by 
primary  union  in  less  than  two  weeks.  One  wound  was  in  the  middle  of  Scarpa's  tri- 
angle, and  the  other  at  the  level  of,  and  one  inch  posterior  to,  the  great  trochanter  on  the 
same  side.  From  the  fact  that  there  was,  as  was  shown  by  the  radiograph,  a  piece  of  the 
jacket  of  a  bullet  in  the  right  popliteal  space,  it  is  probable  that  he  was  wounded  by  a 
plunging  fire,  and  that  the  bullet  inflicted  the  latter  wound  after  emerging  from  the  wound 
in  Scarpa's  triangle.  The  wound  in  the  popliteal  space  suppurated.  Patient  became  very 
weak  and  anemic.  In  the  triangle  directly  under  the  wound  there  was  a  pulsating  swell- 
ing in  the  direction  of  the  femoral  vein,  which  extended  to  Poupart's  ligament.  Vein 
was  much  enlarged.  Fremitus  and  the  characteristic  bruit  extended  to  a  considerable 
distance  above  and  below  the  communicating  opening  between  the  artery  and  vein. 
Owing  to  the  anemic  and  debilitated  condition  of  the  patient,  it  was  deemed  best  to  post- 
pone the  operative  treatment  of  the  aneurysmal  varix  until  his  general  health  was  restored. 
The  treatment  consisted  of  rest  and  tonics.  General  health  of  the  patient  improved,  but 
there  was  no  change  in  the  local  condition.      The  mental  state,  much  impaired  since  the 


WOUXDS    OF   THE    KIDNEY. 


291 


^^■^ 


injury,  gradually  improved.  It  is  possible  that  in  this  and  similar  cases  the  vessel  wounds 
could  be  successfully  sutured  after  separating  them,  under  bloodless  procedure.  If  this 
can  not  be  done  in  dealing  with  the  arterial 
wound,  it  should  certainly  be  faithfully  at- 
tempted in  closing  the  vein  wound,  as  pre- 
servation of  the  lumen  of  this  vessel  is  of 
the  greatest  importance  in  preventing  gan- 
grene should  it  become  necessary  to  ligate 
the  femoral  artery. 

C.A.SE  3. — John  J.  Welch,  Company 
M,  Second  Massachusetts  Volunteers,  was 
wounded   July   1st.      The   bullet  entered 

the    middle    of    Scarpa's    triangle,    three  — — ^n  1  _■  11  • 

inches  below  Poupart's  ligament,  directly     ^  jj  I  "^^  \  [\J/ 

over  the  femoral  arterj-,  and  escaped  at 
a  point  corresponding  with  the  gluteal 
crease  and  to  the  outside  of  the  femur  on 
the  same  side,  perforating  the  base  of  the 
thigh  obliquely  (Fig.  171).  A  well- 
marked  traumatic  aneurj-sm  developed, 
presenting  all  the  physical  signs  charac- 
teristic of  such  a  pathologic  condition. 
The  swelling  was  somewhat  elongated, 
a  little  larger  than  a  hen's  egg,  and  did 
not  increase  in  size  after  the  patient  was 
brought  on  board  the  hospital  ship.  The 
leg  was  somewhat  swollen,  edematous, 
and  painful.  It  was  decided  not  to  inter- 
fere with  the  aneurysm  until  the  patient's 
general  health,  which  was  considerably 
impaired,  could  be  restored,  and  the  oper- 
ation performed  under  more  favorable  au- 
spices. Digital  compression  in  a  case  like 
this  deserves  a  faithful  trial,  and  if  it  fails, 
excision  of  the  injured  portion  of  the  artery 
between  two  double  ligatures  constitutes 
the  ideal  treatment.  As  the  accompany- 
ing vein  is  intact,  if  the  operation  is  done 
under  strict  aseptic  precautions,  it  is  at- 
tended by  verj'  little  risk  of  gangrene  or 
other  .serious  complications  that  might  im- 
pair the  usefulness  of  the  limb. 


Fig.  171. — Gunshot   wound  of  the  femoral 
artery. 


WOUNDS  OF  THE  KIDNEY. 

Injury  of  any  part  of  the  urinary  tract  is  an  accident  that  is 
always  fraught  with  clanger,  and  its  early  recognition  and  prompt 
treatment  are  often  the  means  of  averting  the  dangerous  compli- 
cations that  threaten  life.  Hemorrhage,  urinary  extravasation,  and 
sepsis  are  the  most  common  sources  of  danger  of  wounds  of  the 
urinary  organs,  from  the  kidney  to  the  meatus  of  the  urethra. 

The  reparative  capacity  of  the  kidnc)-  in  the  healing  of  wounds 
was  first  shown  experimentally  in  a  satisfactory  manner  by  Maas. 
He  produced  in  the  lower  animals  different  kinds  of  injuries  of  the 
kidney,  and  found  not  only  that  the  animals  were  quite  tolerant  to 
such  traumatic  insults,  but  that  the  wounds  often  healed  promptly 
and  without  manifest  disturbance  of  the  functional  activity  of  the 
organ.  In  limited  injuries  the  animals  recovered  promptly,  sub- 
sequent examination  of  the  injured  organ  showing  a  scar  and  occa- 
sionally a  circumscribed  cyst.     In  grave  contusions  the  wound  healed 


292  GUNSHOT    WOUNDS. 

at  the  expense  of  the  kidney  substance,  the  organ  almost  entirely- 
disappearing  by  cicatricial  atrophy,  while  the  opposite  kidney  under- 
went compensatory  hypertrophy  and  assumed  the  lost  function  of 
the  kidney  destroyed  by  the  injury  and  the  subsequent  cicatricial 
contraction.  If  any  of  the  larger  vessels  of  the  kidney  were  rup- 
tured, necrosis  of  the  renal  parenchyma  followed,  and  injuries  of 
the  ureter  occasionally  gave  rise  to  hydronephrosis. 

It  has  been  ascertained  since  these  experiments  were  made  that 
wounds  of  the  kidney  not  only  heal,  but  also  that  a  considerable 
loss  of  kidney  substance  is  replaced  by  an  active  process  of  repair. 
This  has  been  determined  not  only  by  experiments  on  the  lower 
animals,  but  also  by  the  clinical  observations  of  Tuffier,  Kiimmell, 
James  Israel,  and  others.  In  consequence  of  such  additional  knowl- 
edge concerning  the  regenerative  capacity  of  the  renal  tissue,  par- 
tial nephrectomy  has  become  a  legitimate  surgical  procedure  in 
well-selected  cases. 

From  an  etiologic  standpoint,  wounds  of  the  kidney  are  classified 
into  (i)  penetrating  and  (2)  lacerated  or  contused  wounds.  In  the 
former  variety  the  visceral  wound  communicates  with  the  surface 
wound  by  a  tubular  or  incised  wound  that  has  penetrated  or  cut  the 
interposed  tissues. 

From  a  practical  standpoint,  such  wounds  are  again  divided  into 
(i)  extraperitoneal  and  (2)  intraperitoneal.  Of  these,  the  latter  are 
more  dangerous,  as  they  are  often  complicated  by  visceral  injuries 
of  other  abdominal  organs,  and  are  attended  by  greater  risk  from 
hemorrhage  and  sepsis.  Moreover,  their  surgical  treatment  is  more 
difficult  and  attended  by  greater  additional  sources  of  danger. 
Lacerated,  ruptured,  or  contused  wounds  are  produced  by  falls, 
blows,  passage  of  a  wagon-wheel,  etc.,  and  are  seldom  accompanied 
by  an  external  wound.  In  this  class  of  cases  the  peritoneum  is 
seldom  torn,  and  the  extravasation  of  blood  and  urine  in  case  the 
capsule  of  the  kidney  is  torn  is  entirely  extraperitoneal.  Wounds  of 
the  kidney  caused  by  indirect  force,  according  to  the  results  of  the 
experiments  and  postmortem  observations  of  Herzog,  are  usually 
found  in  the  region  of  the  pelvis,  while  direct  force  is  more  likely  to 
involve  the  convex  part  of  the  organ.  The  location  and  extent  of 
the  wound,  however,  vary  greatly.  The  kidney  may  be  torn 
from  pole  to  pole  and  transversely,  and  in  some  instances  the 
wounds  radiate  from  a  common  center  in  different  directions. 

Anatomically,  it  is  important  to  distinguish  between  wounds  of 
the  kidney  that  involve  (i)  the  capsule,  (2)  the  pelvis,  and  (3)  the 
parenchyma.  If  the  capsule  is  torn,  blood  and  urine  escape  into 
the  pararenal  tissues  if  the  parietal  peritoneum  is  intact ;  and  if  this 
is  punctured  or  lacerated,  the  extravasation  may  take  place  wholly 
or  in  part  into  the  peritoneal  cavity.  If  the  renal  wound  communi- 
cates with  the  pelvis  and  the  capsule  is  intact,  hematuria  presents 
itself  as  the  main  symptom  of  the  injury.  Wounds  between  the 
pelvis  and  the  capsule,   implicating  only  the   parenchyma   of  the 


SYMPTOMS    AND    DIAGNOSIS.  293 

organ,  are  not  attended  by  much  danger  from  hemorrhage,  as  the 
pressure  caused  by  the  extravasation  and  resistance  of  the  capsule 
of  the  kidney  Hmits  the  bleeding  and  the  extravasation  of  urine. 

Symptoms  and  Diagnosis. — In  penetrating  gunshot  wounds 
of  the  abdomen  implicating  the  kidney,  and  in  severe  crushing  in- 
juries, shock  is  a  prominent  and  grave  symptom.  The  severe  hem- 
orrhage present  in  such  cases  intensifies  the  shock.  There  are 
cases  in  which  a  blow  against  the  lumbar  region  is  followed  by 
hematuria  and  slight  renal  colic.  I  have  seen  a  number  of  such 
cases  in  which  recovery  appeared  to  be  complete  in  a  few  days. 
The  injury  in  such  instances  evidently  consists  in  a  slight  tear  of 
the  kidney  substance,  the  blood  finding  its  way  into  the  pelvis  of 
the  kidney  through  the  torn  uriniferous  tubules,  or  a  slight  tear  may 
extend  into  the  pelvis  and  heal  in  a  short  time  simultaneously 
with  the  wound  of  the  parenchyma. 

These  mild  cases  are  quite  in  contrast  to  those  in  which  the  in- 
jury is  attended  by  severe  shock  and  hemorrhage.  Lumbar  pain 
and  tenderness  accompany  every  kidney  wound,  and  the  pain,  as  in 
renal  colic,  usually  extends  in  the  direction  of  the  ureter  to  the 
groin,  testicle,  and  inner  surface  of  the  thigh.  Frequent  desire  to 
urinate  and  hematuria  are  early  and  often  distressing  symptoms. 
The  coagulation  of  blood  in  the  bladder  seriously  interferes  with 
the  evacuation  of  this  organ  spontaneously  or  by  the  use  of  the 
catheter.  The  blocking  of  the  ureter  is  also  responsible  for  the 
renal  colic  caused  by  the  retention  of  urine  in  the  pelvis  of  the  kid- 
ney. The  coagula  that  escape  with  the  urine  sometimes  correspond 
in  form  to  the  lumen  of  the  ureter  or  pelvis  of  the  kidney,  in  which 
event  the  kidney  can  safely  be  assumed  to  be  the  source  of  hemor- 
rhage. Ordinaril}^  the  hematuria  disappears  in  a  few  days  in  cases 
that  do  not  require  operative  treatment,  but  it  may  be  prolonged 
for  two  to  six  weeks,  leading  to  pronounced  anemia,  and  yet  recov- 
ery may  take  place  eventually.  In  a  few  cases  injuiy  of  one  kidney 
has  given  rise  to  complete  suppression  of  urine.  Such  result  is 
generally  caused  by  absence,  atrophy,  or  disease  of  the  opposite 
kidney,  or  of  the  wounded  kidney  if  a  horseshoe  kidney. 

Fever  and  other  constitutional  disturbances  of  a  more  or  less 
violent  character  may  occur  independently  of  infection,  and  must 
then  be  attributed  to  fibrin  intoxication.  The  general  symptoms 
from  this  cause  usually  set  in  a  few  hours  after  the  injury,  while 
fever  caused  by  infection  is  a  more  remote  complication. 

In  penetrating  wounds  of  the  kidney  in  connection  with  an 
abdominal  injury,  swelling  in  the  lumbar  region  may  be  slight  or 
entirely  absent,  the  blood  and  urine  escaping  into  the  peritoneal 
cavity.  In  the  ab.sencc  of  such  a  communicating  opening  with  the 
peritoneal  cavity,  any  considerable  wound  of  the  kidney  with  rup- 
ture of  its  capsule  is  soon  followed  by  a  swelling  in  the  lumbar 
region.  A  swelling  that  appears  within  a  few  hours  after  the  injury 
is   the    result  of  hemorrhage,  and  the   sooner  it  appears  and  the 


294  GUNSHOT   WOUNDS. 

larger  it  is,  the  more  profuse  is  the  hemorrhage  and  the  greater  is 
the  urgency  for  operative  interference. 

The  gradual  increase  of  the  swelling  after  the  hemorrhage  has 
ceased  is  caused  by  the  extravasation  of  urine.  The  appearance 
of  such  a  swelling  shortly  after  an  injury  indicates  the  existence  of 
a  wound  of  the  kidney,  notwithstanding  that  hematuria  may  be 
absent.  In  penetrating  wounds  of  the  kidney  the  hemorrhage  may 
be,  in  part,  external,  and  this  is  more  especially  the  case  if  the 
bullet  or  knife  has  not  penetrated  the  abdominal  cavity. 

As  late  complications  of  wounds  of  the  kidney,  important  from 
a  diagnostic  standpoint,  must  be  mentioned  suppurative  interstitial 
nephritis.  If  a  number  of  small  abscesses  become  confluent  large 
abscess  cavities,  they  eventually  lead  to  complete  destruction  of 
the  kidney.  Retention  of  urine  in  the  pelvis  of  the  kidney  from 
ureteral  obstruction  by  coagulated  blood  predisposes  to  the  develop- 
ment of  suppurative  pyelonephritis.  The  extravasation  of  blood 
and  urine  around  the  kidney  leads  to  paranephric  abscesses.  If, 
in  a  case  of  kidney  wound,  the  primary  symptoms  do  not  warrant 
a  resort  to  operative  interference,  the  surgeon  must,  from  day  to 
day,  search  for  symptoms  indicating  the  existence  of  infection. 
When  such  symptoms  do  appear,  he  must  again  carefully  consider 
the  propriety  of  meeting  them  in  time  by  appropriate  surgical  inter- 
vention, as  many  such  patients  succumb  to  late  comphcations  from 
this  source. 

Prognosis. — The  prognosis  is  always  grave  in  penetrating 
wounds  of  the  kidney  when  the  missile  or  knife  has  penetrated  the 
peritoneal  cavity.  Edler  collected  50  cases  of  gunshot  wound  of 
the  kidney,  and  of  these,  28  recovered.  Of  the  20  uncomplicated 
cases,  only  three  died.  The  most  frequent  causes  of  death  are  hem- 
orrhage, peritonitis,  and  septicopyemia.  Of  1 2  cases  of  stab  wounds, 
7  recovered  and  5  died.  Bobroff  ascertained  the  result  in  141  cases 
of  rupture  of  the  kidney,  of  which  number  75  recovered  and  66 
died. 

The  large  mortality  of  wounds  of  the  kidney  will  be  materially 
reduced  as  soon  as  the  importance  of  early  operative  treatment  in 
grave  cases  is  more  generally  recognized  and  practised.  The  anti- 
septic treatment  of  the  complicating  wound  and  early  operations 
under  strict  aseptic  precautions  will  do  much  in  the  prevention  of 
death  from  septic  complications.  The  modern  technic  of  hemo- 
stasis  will  enable  the  surgeon  to  deal  more  efficiently  with  hemor- 
rhage in  the  future  than  has  been  the  case  in  the  past.  The  prog- 
nosis must  depend  on  the  extent  of  the  injury,  the  severity  of  the 
hemorrhage,  the  presence  or  absence  of  intraperitoneal  complica- 
tions, and  the  condition  of  the  opposite  kidney.  A  wound  of  a 
horseshoe  kidney  is  always  of  grave  import.  If  the  opposite  kidney 
is  diseased  or  fails  to  assume  compensatory  function,  death  from 
uremia  may  be  expected.  There  are  cases,  too,  in  which  injury 
of  one  kidney  is  productive  of  sympathetic  disease  of  the  other, 


TREATMENT.  295 

when  life  is  again  jeopardized  from  a  similar  complication.  With 
the  appearance  of  septic  complications  the  prognosis  is  again  modi- 
fied by  the  location  and  extent  of  the  septic  infection,  and  the  gen- 
eral condition  of  the  patient  from  the  primary  effects  of  the  injury. 

Treatment. — Rest  of  the  injured  organ  and,  if  it  exists,  anti- 
septic dressing  of  the  external  wound,  constitute  the  most  important 
first-aid  measures.  If  the  hemorrhage  is  severe,  the  recumbent 
position  must  be  enforced,  the  patient  being  disturbed  as  little  as 
possible  until  the  bleeding  is  under  control.  Probing  of  gunshot 
and  stab  wounds  is  not  permissible,  as  little  or  nothing  is  gained  in 
determining  the  location  and  extent  of  the  injury,  and,  on  the  other 
hand,  meddlesome  treatment  of  this  kind  carries  with  it  additional 
risks  of  hemorrhage  and  infection.  As  long  as  hemorrhage  is 
present,  stimulants  are  contraindicated.  The  administration  of  a 
full  opiate  is  favored  by  the  best  authorities.  Water  by  the  mouth 
or  saline  solution  by  the  rectum  will  prove  useful  in  quenching 
thirst  and  in  counteracting  shock.  The  internal  use  of  hemostatics, 
such  as  gallic  acid,  tannin,  and  ergot,  is  worse  than  useless. 

If  the  injury  is  of  sufficient  severity  to  endanger  life  from  hem- 
orrhage, urine  extravasation,  or  both,  no  time  should  be  lost  in 
exposing  the  injured  kidney  for  direct  operative  treatment.  The 
value  of  timely  surgical  aid  in  such  cases  has  recently  been  demon- 
strated by  Keen  in  his  classic  monograph  on  this  subject.  In 
penetrating  wounds  of  the  abdomen  complicated  by  injury  of  the 
kidney,  treatment  by  laparotomy  is  the  proper  course  to  pursue.  If, 
on  opening  the  abdomen,  no  other  visceral  lesions  are  found,  the 
kidney  is  exposed  by  holding  the  intestines  out  of  the  way  with 
compresses  wrung  out  of  a  hot  saline  solution,  and  incising  the 
parietal  peritoneum  sufficiently  to  give  access  to  the  wound.  If 
the  hemorrhage  is  severe  and  the  pelvic  part  of  the  kidney  is 
injured,  nephrectomy  should  be  performed  at  once,  by  lifting  the 
kidney  out  of  its  cushion  of  fat,  ligating  the  pedicle  with  strong 
silk,  and  cutting  it  at  a  .safe  distance  from  the  ligature.  Abdominal 
nephrectonix'  under  such  circumstances  has  this  one  great  advantage, 
that  the  surgeon  can  satisfy  himself  of  the  presence  and  exact  con- 
dition of  the  opposite  kidney  by  direct  palpation.  A  counteropen- 
ing  in  the  lumbar  region  large  enough  to  permit  free  gauze  drainage 
should  always  be  made  before  closing  the  peritoneal  wound. 
Washing  out  of  the  abdominal  cavity  with  hot  saline  solution  is 
most  effective  in  removing  the  extravasated  blood  and  urine,  and  in 
counteracting  the  depressing  effects  of  the  injury  and  the  operation. 

If  the  operation  is  performed  before  peritonitis  has  had  time  to 
develop,  abdominal  drainage  can  be  disi)ensed  with.  If  the  bullet 
or  knife-blade  has  injured  the  intestines  or  any  other  abdominal 
organ,  the  first  duty  of  the  surgeon  is  to  arrest  hemorrhage  from 
the  kidney  or  any  other  source  by  compression,  until  the  visceral 
injuries  have  been  dispo.sed  of,  when  the  kidney  is  dealt  with  in  the 
manner  described.      If  the  kidney  wound  does  not  furnish  an  ade- 


296 


GUNSHOT    WOUNDS. 


Fig.  172. — Proper  position  of  patient  for  operation 
on  the  kidney,  and  Simon's  vertical  incision  (Esmarch 
and  Kowalzig). 


quate  indication  for  nephrectomy,  it  is  tamponed  with  sterile  gauze 
that  is  brought  out  through  a  lumbar  incision  and  depended  upon 
in  arresting  the  bleeding  and  in  securing  free  drainage.  If  this 
course  is  pursued,  the  parietal  peritoneum  is  carefully  sutured  over 
the  kidney,  followed  by  the  toilet  of  the  peritoneal  cavity.     Under 

such  conditions  it  is 
advisable  to  drain  the 
peritoneal  cavity  long 
enough  to  avoid  the 
immediate  risks  of  urine 
extravasation,  as  this 
might  occur  in  spite  of 
suturing  of  the  parietal 
peritoneum  over  the  in- 
jured kidney. 

In  the  treatment 
of  all  extraperitoneal 
wounds  of  the  kidney,  the  proper  route  to  the  injured  organ  is 
through  the  lumbar  region.  Simon's  vertical  incision,  commenc- 
ing over  the  eleventh  rib,  at  the  outer  border  of  the  sacrolumbalis 
muscle,  and  extended  downward  to  near  the  crest  of  the  ilium, 
affords  sufficient  access  to  the  kidney  for  the  thorough  examina- 
tion and  treatment  of  wounds  that 
do  no  not  involve  extirpation.  The 
capsule  of  fat  is  next  incised,  and 
the  organ  brought  into  the  wound 
for  inspection.  Bleeding  is  arrested 
by  suturing  or  tampon,  the  latter 
preferably,  as  suturing  is  often 
found  difficult  and  the  sutures 
readily  tear  through  the  capsule 
when  subjected  to  tension.  The 
external  wound  should  be  left 
open  and  packed  with  sterile 
gauze.  If  the  kidney  is  injured 
or  diseased,  iodoform  gauze  must 
be  used  sparingly,  as  such  patients 
are  very  susceptible  to  iodoform 
intoxication. 

If  a  nephrectomy,  owing  to 
the  extent  of  the  injury  or  the 
severity  of  the  hemorrhage,  is 
decided  upon,  the  vertical  incision 
is  joined  by  a  transverse  one, 
which  is  carried  extraperitoneally  along 
the  last  rib.  It  should  be  long  enough 
to    the    hilum  of  the    kidney,    the  ureter, 


Fig-  173- — Nephrectomy  through 
transverse  incision  (Esmarch  and  Kowal- 
z'g)- 


the  lower  margin  of 
to  secure  free  access 
and    the  renal  vessels. 


Catgut   should  not  be   relied  upon  in  tying  the  pedicle,  and  the 


WOUNDS    OF    THE    URINARY    BLADDER.  29/ 

latter  must  be  cut  at  a  sufficient  distance  from  the  ligature  to 
prevent  its  slipping. 

After  nephrectomy,  the  wound  is  sutured  and  drained.  The 
subcutaneous  or  rectal  administration  of  saline  solution  will  do 
much  toward  stimulating  the  function  of  the  remaining  kidney.  One 
of  the  distressing  conditions  in  wounds  of  the  kidney  with  hem- 
orrhage into  its  pelvis  is  the  accumulation  of  blood  in  the  bladder, 
which,  after  coagulation  has  taken  place,  is  most  difficult  to  remove. 
A  large  Nelaton  catheter  is  inserted,  and  if  the  blood-clots  do  not 
escape,  aspiration  is  made  with  a  syringe.  Should  this  fail,  evac- 
uation of  the  bladder  by  perineal  section  or  suprapubic  cystotomy 
must  be  effected  without  much  delay.  In  either  case  the  bladder 
must  be  drained  until  hemorrhage  has  ceased. 

The  secondary  complications  after  injury  of  the  kidney  demand 
prompt  surgical  interference.  Suppurative  interstitial  nephritis, 
pyelonephritis,  and  paranephric  abscess  must  be  met,  as  soon  as 
discovered,  by  lumbar  incision  and  nephrectomy,  according  to  the 
location  of  the  focus  of  infection.  Secondary  nephrectomy  may 
become  necessary  for  the  removal  of  a  kidney  made  useless  by  the 
injury  and  subsequent  inflammatory  complications. 

WOUNDS  OF  THE  URINARY  BLADDER. 

Wounds  of  the  bladder  are  inflicted  b}^  the  penetration  of  the 
organ  by  a  bullet,  knife,  or  any  other  implement,  or  by  a  sharp  frag- 
ment of  bone  in  fractures  of  the  pelvis  complicated  by  a  visceral  in- 
jury of  the  bladder,  or  by  compression  of  this  organ  when  distended. 
The  liability  to  injury  of  the  bladder  from  this  kind  of  traumatism  is 
in  proportion  to  the  size  of  the  organ.  If  the  bladder  is  empty,  it  is 
out  of  the  way  of  some  of  the  routes  traversed  by  penetrating  mis- 
siles or  instruments.  It  would  be  expected,  therefore,  that  in  the 
majority  of  cases  of  penetrating  wounds  of  the  bladder  the  organ 
was  more  or  less  distended  at  the  time  the  injury  was  received,  and 
consequently  escape  of  urine  through  the  wound  would  constitute 
an  early  symptom  and  source  of  danger. 

Bullet  wounds  may  occur  at  any  point  where  the  missile  pene- 
trates the  bony  wall  or  soft  tissues  of  the  pelvis,  but  other  penetra- 
ting wounds  are  observed  most  frequently  in  places  where  the 
bkidder  is  covered  by  soft  tissues  only.  The  puncture  is  then  made 
through  the  hypogastrium,  vagina,  rectum,  or  sacrosciatic  foramen. 

Rupture  of  the  bladder  by  compression,  as  has  been  shown  by 
clinical  observations  and  the  results  of  experiments,  is  almost  always 
associated  with  distention.  This  accident  is  seen  most  frequently 
in  persons  under  the  influence  of  liquor,  when  injured  by  a  fall  or 
blow.  Garre  has  demonstrated  that  rupture  of  the  bladder  from  a 
blow  again.st  the  hypogastrium  is  mo.st  likely  to  occur  when  the 
abdominal  muscles  are  ten.se.  Rupture  of  the  bladder  by  compres- 
sion of  the  distended  organ  occurs  most  frequently  in  the  posterior 
wall,  but  it  may  occur  in  almost  any  [^art  of  the  wall,  as  not  an  in- 


298  GUNSHOT    WOUNDS, 

considerable  number  of  cases  have  been  recorded  in  which  the  vis- 
ceral wound  was  extraperitoneal.  If  the  wound  is  intraperitoneal, 
urine  escapes  into  the  free  peritoneal  cavity  ;  if  it  is  extraperitoneal, 
extravasation  of  urine  into  the  loose  paravesical  connective  tissue  is 
the  immediate  or  more  remote  consequence  of  the  injury.  If  the  an- 
terior wall  of  the  bladder  below  the  peritoneal  reflection  is  torn,  in- 
filtration of  the  cavity  of  Retzius  produces  a  sweUing  which,  in  shape 
and  location,  mimics  very  closely  a  distended  bladder. 

Symptoms  and  Diagnosis. — In  penetrating  wounds  of  the  blad- 
der the  character  of  the  symptoms  is  determined  by  the  location  of 
the  wound.  A  bullet  frequently  inflicts  two  wounds,  of  which  one 
may  be  extraperitoneal,  the  other  intraperitoneal,  or  both  may  be  in- 
traperitoneal or  extraperitoneal.  In  exceptional  cases  in  which  only 
one  extraperitoneal  wound  exists,  escape  of  urine  through  the 
wound  furnishes  sufficient  evidence  that  the  bladder  is  injured,  and 
would  tend  to  prove  the  absence  of  an  additional  intraperitoneal 
wound.  Punctured  wounds  through  the  vagina  or  rectum  may 
also  be  either  extraperitoneal  or  intraperitoneal,  according  as  the 
wound  is  either  below  or  above  the  reflection  of  the  peritoneum. 
In  the  former  case,  escape  of  all  the  urine  through  the  wound 
would  exclude  the  existence  of  another  intraperitoneal  wound  ;  in 
the  latter  instance,  part  of  the  urine  may  escape  through  the  injured 
passage  and  part  into  the  peritoneal  cavity. 

In  rupture  of  the  bladder  the  urine  escapes  either  into  the  peri- 
toneal cavity  or  into  the  surrounding  connective  tissue,  according 
to  the  intraperitoneal  or  extraperitoneal  location  of  the  rent.  If  the 
rupture  is  small  and  intraperitoneal,  and  especially  if  the  bladder  is 
not  much  distended,  the  urine  extravasation  may  be  slight,  the 
wound  becoming  blocked  by  adhesions  a  few  hours  after  the  injuiy. 
Such  a  condition  accounts  for  the  recovery,  without  surgical  inter- 
vention, of  two  out  of  eighty  cases  of  intraperitoneal  rupture  of  the 
bladder  reported  by  Stephen  Smith. 

The  two  symptoms  that  may  be  most  relied  upon  in  diagnosti- 
cating perforation  or  rupture  of  the  bladder  are  hemorrhage  and  an 
empty  bladder.  An  extraperitoneal  wound  of  the  bladder  is  char- 
acterized by  the  profuseness  of  the  hemorrhage  ;  an  intraperitoneal 
rupture  of  the  posterior  wall,  by  the  escape  of  all  the  urine  into  the  per- 
itoneal cavity.  In  the  former  case  an  extraperitoneal  phlegmonous 
inflammation  is  the  usual  result  of  the  injury  ;  in  the  latter,  physi- 
cal signs  pointing  to  the  accumulation  of  fluid  (blood  and  urine)  in 
the  peritoneal  cavity  furnish  reliable,  almost  unmistakable,  evidence 
of  the  existence  of  an  intraperitoneal  perforation  or  rupture.  In- 
ability to  void  urine  and  the  appearance  of  an  intraperitoneal  or  ex- 
traperitoneal swelling  must  always  arouse  strong  suspicion  of  the 
existence  of  a  wound  of  the  bladder. 

If  any  doubt  remains  in  regard  to  the  location  of  the  rupture,  a 
suprapubic  incision  will  become  an  important  diagnostic  aid  and  a 
valuable  therapeutic  resource.      If  the  extraperitoneal  part  of  the  an- 


PROGNOSIS. 


299 


terior  wall  of  the  bladder  has  been  ruptured,  the  wound  is  immedi- 
ately discovered,  and  the  incision  at  once  determines  the  diagnosis 
and  constitutes  the  proper  surgical  treatment.  Through  the  visceral 
wound  the  bladder  is  explored  for  additional  injuries,  and  if  none  is 
found,  free  drainage  of  the  bladder  completes  the  operation.  If  the 
anterior  wall  of  the  bladder  is  found  intact,  the  bladder  is  opened 
extraperitoneally,  and  by  digital  exploration  a  wound  in  the  poste- 
rior wall  can  be  detected,  if  such  exists,  and  the  necessary  radical 
treatment  by  abdominal  section  and  suturing  of  the  wound  instituted 
at  once. 

The  subjective  symptoms  in  rupture  of  the  bladder  are  often 
slight,  and  this  is  especially  true  in  persons  under  the  influence  of 
alcohol.  Probing  as  a  diagnostic  resource  in  gunshot  and  punc- 
tured wounds  of  the  bladder  must  be  dispensed  with,  as  it  is  an 


Fig.  174. — Suprapubic  incision  of  the  bladder  by  Bardenheuer's  transverse  incision  ; 
suturing  of  the  visceral  to  the  external  wound :  a.  As  seen  from  above  ;  b,  as  seen  in 
section  (Esmarch  and  Kowalzig). 


unreliable  and  often  dangerous  procedure.  Inflation  of  the  bladder 
with  hydrogen  gas  or  filtered  air  through  a  soft-rubber  catheter  was 
first  suggested  by  Keen  as  a  diagnostic  aid,  and  in  doubtful  cases 
should  always  be  resorted  to.  If  the  bladder  is  wounded,  the  gas 
or  air  will  escape  through  the  wound  into  the  peritoneal  cavity  if 
the  wound  is  intraperitoneal,  or  into  the  loose  paravesical  connective 
tissue  if  it  is  extraperitoneal.  It  will  do  no  harm  in  either  locality, 
and  will  at  once  confirm  or  correct  the  clinical  diagnosis.  Injection 
of  a  warm  normal  salt  solution  will  answer  the  same  purpose.  If 
the  bladder  can  not  be  distended  by  inflation  or  injection,  the  exist- 
ence of  a  rupture  or  perforation  has  been  established,  and  no  time 
should  be  lost  in  resorting  to  the  necessary  operative  treatment. 

Prognosis. — The  prognosis  of  wounds  of  the  bladder,  whether 
produced  by  penetration  or  rupture,  is  always  grave.     In  default  of 


300  GUNSHOT    WOUNDS. 

prompt  surgical  intervention  the  extraperitoneal  wounds  are  followed 
by  diffuse  phlegmonous  inflammation,  abscess  formation,  sepsis,  and 
death  in  the  majority  of  cases  ;  and  intraperitoneal  wounds,  with  few 
exceptions  indeed,  result  in  death  from  progressive  septic  peritonitis. 
The  dangerous  symptoms  are  usually  delayed  for  a  day  or  two,  but 
when  once  developed,  they  progress  rapidly  to  a  fatal  termination. 
The  prognosis  is  vastly  better  in  extraperitoneal  than  in  intraperi- 
toneal wounds,  as  in  the  former  case  a  timely  incision  of  the  abscess 
following  in  the  course  of  the  phlegmonous  inflammation  may  suc- 
ceed in  averting  death  from  sepsis.  The  subsequent  urinary  fistula 
not  infrequently  heals  spontaneously,  especially  when  the  bladder  is 
eliminated  as  a  reservoir  for  the  urine  for  a  sufficient  length  of  time 
by  the  employment  of  permanent  urethral  or  perineal  drainage.  The 
septic  peritonitis  which  so  constantly  sets  in  a  day  or  two  after  the 
injury  in  intraperitoneal  wounds  of  the  bladder  is  often  provoked  by 
catheterization. 

According  to  Maltrait,  of  97  cases  of  intraperitoneal  wounds  of 
the  bladder,  only  one  recovered  after  laparotomy  and  suturing  of  the 
visceral  wound,  and  this  case  was  reported  by  Walter,  of  Pitts- 
burg, while  of  "j^  extraperitoneal  wounds,  recovery  is  said  to  have 
taken  place  in  29.  Rivington  collected  322  cases  of  rupture  of  the 
bladder,  of  which  number  183  were  extraperitoneal  and  119  intra- 
peritoneal. Of  the  whole  number,  only  27  recovered,  and  among 
these  was  only  one  in  which  the  wound  was  intraperitoneal — the 
case  reported  by  Walter.  Prompt  surgical  intervention  has  suc- 
ceeded in  reducing  this  enormous  mortality  materially,  and  is  the 
best  possible  proof  of  the  pressing  necessity  of  making  an  early  and 
a  correct  diagnosis,  and  of  subjecting  the  visceral  wound  to  direct 
treatment. 

Treatment. — The  experiments  of  Vincent  and  Maltrait  have 
shown  the  value  of  early  laparotomy  and  suturing  of  the  vesical 
wound  as  life-saving  measures  in  the  treatment  of  intraperitoneal 
wounds  of  the  bladder.  They  ascertained  that  laparotomy  without 
suturing  of  the  wound  of  the  bladder  had  but  little,  if  any,  influ- 
ence in  preventing  death  from  peritonitis.  In  intraperitoneal  wounds 
of  the  bladder  the  abdomen  should  be  opened  under  the  strictest 
aseptic  precautions  as  soon  as  possible  after  the  accident,  for  the 
purpose  of  removing  the  products  of  extravasation  of  blood  and 
urine  and  to  procure  free  access  to  the  visceral  wound,  which  is  then 
carefully  sutured.  After  opening  the  abdomen,  the  peritoneal  cavity 
should  be  thoroughly  cleansed  by  irrigation  with  a  warm  normal 
salt  solution,  and  mopped  with  gauze  or  sea-sponges.  If  the  wound 
of  the  bladder  is  not  readily  discovered,  the  same  solution  is  injected 
into  the  bladder  through  an  elastic  catheter,  when  the  escaping  fluid 
will  indicate  the  existence  and  location  of  the  wound.  The  catheter 
is  retained  in  the  bladder,  and  is  fastened  in  position  and  utilized 
later  to  drain  the  bladder  by  siphonage.  This  is  accomplished  by 
attaching    to    the  distal   end   of  the  catheter  rubber   tubing    long 


TREATMENT.  3OI 

enough  to  reach  from  the  bed  to  the  receptacle  for  the  urine,  placed 
two  or  three  feet  below  the  level  of  the  neck  of  the  bladder.  The 
distal  end  of  the  rubber  tube  is  immersed  in  an  antiseptic  solution. 

After  the  peritoneal  cavity  has  been  thoroughly  cleansed,  the 
perforation  or  rent  in  the  bladder  is  sutured,  somewhat  in  the  same 
manner  as  an  intestinal  wound.  If  the  margins  of  the  wound  are 
ragged,  they  are  trimmed  with  scissors.  The  first  row  of  sutures 
should  be  made  with  absorbable  material,  preferably  of  fine  cat- 
gut, and  should  include  all  the  coats  of  the  bladder  except  the 
mucosa.  The  second  row  of  sutures  of  fine  silk  is  intended  to  bury 
the  first  row,  and  to  bring  in  contact  the  serous  surfaces.  The 
stitches  are  inserted  in  the  same  manner  as  the  Lembert  stitches  are 
inserted  in  suturing  an  intestinal  wound.  The  stitches  in  both  rows 
of  sutures  are  placed  very  closely,  to  secure  hermetic  closure  of  the 
wound.  After  the  suturing  has  been  completed,  the  bladder  is 
moderately  distended  by  injecting  normal  salt  solution,  and  if  any 
leakage  is  detected,  the  defect  is  remedied  by  inserting  additional 
sutures.  Urethral  drainage  b\^  siphonage  is  continued  until  the 
peritoneal  surfaces  have  become  firmly  agglutinated  ;  that  is,  for  at 
least  from  forty-eight  to  seventy-two  hours.  After  this  time  it  will 
be  necessar}^  for  a  number  of  days,  to  evacuate  the  bladder  every 
four  hours  by  aseptic  catheterization.  Drainage  of  the  abdominal 
wound  for  forty-eight  hours  is  advisable. 

Schlange  has  recently  collected  32  cases  of  rupture  of  the 
bladder  treated  by  operative  intervention.  Of  these  cases,  22  were 
intraperitoneal  and  10  extraperitoneal  ;  of  this  number  17  recovered, 
and  of  the.se,  in  10  the  rupture  was  intraperitoneal,  and  in  the 
remaining  7  extraperitoneal.  In  extraperitoneal  wounds  of  the 
bladder  drainage  of  the  bladder  by  siphonage  has  occasionally 
sufficed  to  prevent  dangerous  extravasation  and  to  effect  healing 
of  the  visceral  wound.  It  is,  however,  much  safer  not  to  rely  on 
this  treatment  in  such  cases,  but  to  resort  at  once  to  a  suprapubic 
cystotomy,  search  for  and,  if  found,  make  an  attempt  to  close  the 
wound  by  suturing.  If  this  can  not  be  done,  suprapubic  drainage 
through  the  operation  wound  should  be  continued  until  the  rup- 
ture or  perforation  is  healed. 


CHAPTER  VIII. 

RUPTURE  OF  THE  URETHRA* 

Rupture  of  the  urethra  is  of  either  traumatic  or  pathologic  ori- 
gin. Of  the  former,  external  crushing  injuries  and  unskilful  or 
forced  catheterization  are  the  most  frequent  causes.  Pathologic 
rupture  of  the  urethra  follows  usually  upon  the  footsteps  of  peri- 
urethral abscess,  stricture,  or  malignant  disease  of  any  part  of  the 
urethra.  Regardless  of  the  nature  of  the  immediate  cause,  rupture 
of  the  urethra  endangers  life  by  urine  retention,  urine  infiltration, 
gangrene,  phlegmonous  inflammation,  and  abscess  formation.  As 
traumatic  rupture  is  vastly  more  frequent  than  the  pathologic 
variety,  the  remarks  will  apply  more  especially  to  this  etiologic 
variety  of  rupture  of  the  urethra. 

Traumatic  rupture  of  the  urethra  is  an  accident  that  belongs  to 
emergency  surgery,  and  is,  consequently,  a  subject  of  the  greatest 
importance  and  interest  to  the  general  practitioner.  It  is  strange, 
but  nevertheless  true,  that  most  authors  on  operative  surgery  do 
not  treat  this  subject  with  the  necessary  degree  of  detail  and  thor- 
oughness for  the  instruction  of  the  general  practitioner.  Terrillon, 
a  painstaking  author,  classifies  traumatic  ruptures  of  the  urethra 
anatomically  into  :  (i)  Interstitial  (first  degree);  (2)  rupture  of  the 
mucosa  and  submucosa  (second  degree)  ;  (3)  rupture,  either  com- 
plete or  incomplete,  of  all  the  coats  (third  degree).  This  classifica- 
tion is  of  very  slight  clinical  value  before  operation,  as  a  differential 
diagnosis  is  often  impossible  without  direct  inspection  of  the  tissues 
exposed  by  the  incision. 

The  classification  of  Oberst  is  simpler  and  of  greater  practical 
value.  He  recognizes  and  describes  two  degrees  :  (i)  Partial  rup- 
ture without  destroying  the  continuity  of  the  tube ;  (2)  complete 
rupture,  destroying  the  continuity  of  the  tube,  an  injury  that  will 
be  almost  certain  to  be  followed  by  urinary  infiltration  unless 
prompt  surgical  interference  is  instituted  to  prevent  it.  According 
to  Oberst,  the  injury  occurs  in  the  following  manner: 

With  the  limbs  separated,  the  person  falls  astride  some  object, 
which  strikes  the  perineum.  In  consequence  of  such  impact  the 
perineum  and  urethra  are  forced  against  the  sharp  margin  of  the 
pubic  arch.  As  the  urethra  is  connected  with  this  arch  by  the 
puboprostatic  ligament,  the  injuring  force  is  concentrated  at  this 
point.  If  the  force  is  directed  more  to  one  side  of  the  median  line, 
the  urethra  is  crushed  against  the  descending  ramus  of  the  pubis. 
The  overlying  skin,  which  is  more  elastic  than  the  urethral  tissues, 
usually  remains  intact. 

302 


ETIOLOGY.  303 

Oberst's  conception  of  the  modus  operandi  of  the  trauma  has 
been  fully  corroborated  by  the  experimental  work  of  Terrillon. 
Poncet  and  Oilier  claim  that  not  all  ruptures  of  the  urethra  are 
caused  by  direct  impact  against  the  pubis.  They  maintain  that  the 
force  is  directed  against  the  triangular  ligament,  which  severs  the 
urethral  roof.  They  made  experiments  by  inserting  bougies  of  soft 
wax  into  the  urethra  of  cadavers,  and  then  striking  the  perineum 
with  force.  The  wax  always  showed  impressions  made  by  the  liga- 
ment. They  believe  that  this  method  of  rupture  applies  only  to  the 
membranous  portion  of  the  urethra,  agreeing  with  others  that  the 
bulbous  portion  is  severed  by  pressure  against  the  pubis. 

Kaufmann  gives  the  statistics  of  the  cause  of  urethral  rupture  in 
239  cases  as  follows  :  198,  or  82  per  cent.,  were  due  to  injuries 
caused  by  falling  astride  of  some  hard,  sharp-margined  object ;  28, 
or  12  per  cent.,  were  caused  by  a  blow  upon  the  perineum  ;  9,  or 
4  per  cent.,  resulted  from  an  injury  by  being  thrown  upon  the  pom- 
mel of  a  saddle.  In  fractures  of  the  pelvis,  especially  of  the  pubic 
portion,  the  deep  urethra  is  almost  invariably  torn,  or  the  escape  of 
urine  is  impeded  or  arrested  by  pressure  of  a  fragment  upon  the 
urethral  canal. 

In  fractures  of  the  pelvic  ring,  the  deep  urethra,  with  the  excep- 
tion of  the  prostatic  portion,  is  especially  liable  to  injury,  owing  to  its 
manner  of  fixation  by  the  triangular  ligament.  Gosselin  is  of  the  opin- 
ion that  fractures  of  the  pelvis  usually  result  in  only  partial  rupture 
of  the  urethra.  In  all  the  cases  studied  by  Oberst  the  urethra  was 
found  completely  severed  in  such  injuries.  In  severe  contusions  of 
the  pelvis  there  may  be  rupture  by  reason  of  momentary  disjunc- 
tion of  the  symphysis  pubis.  A  few  cases  have  been  reported  in 
which  rupture  of  the  urethra  was  caused  by  violent  abduction  of 
the  thigh,  in  which  case  the  rupture  must  be  attributed  to  muscular 
action. 

Rupture  of  the  urethra  from  careless  instrumentation  occurs 
most  frequently  during  attempts  at  catheterization  in  patients  suffer- 
ing from  stricture  or  hypertrophy  of  the  prostate.  Rupture  of  the 
pendulous  portion  of  the  urethra  is  of  veiy  rare  occurrence,  and 
when  it  does  take  place,  is  due  to  violence  sustained  during  erec- 
tion of  the  penis. 

It  is  not  always  possible  to  locate,  with  precision,  the  anatomic 
location  of  the  rupture.  The  relative  frequency  with  which  the 
bulbous  and  membranous  portions  are  involved  is  not  definitely 
settled.  Terrillon  described  9  cases,  6  of  the  bulbous  and  3  of  the 
membranous  portion.  Oberst  reported  the  results  of  5  autopsies  in 
which  the  ru[)ture  was  found  four  times  in  the  membranous  and 
only  once  in  the  bulbous  part  of  the  urethra. 

The  clinical  recognition  of  a  rupture  of  the  urethra  is  not  diffi- 
cult, but  the  prediction  of  the  extent  of  the  injury  often  remains 
uncertain.  Hemorrhage  from  the  urethra  furnishes  an  indication  of 
the  existence  of  the  injury,  but  the  amount  of  hemorrhage  is  not  a 


304  RUPTURE  OF  THE  URETHRA. 

criterion  as  to  the  extent  of  the  injury.  The  artery  of  the  bulb 
might  be  torn  by  a  sHght  rupture,  in  which  case  the  bleeding  would 
be  profuse  ;  while,  on  the  other  hand,  a  complete  rupture  of  the 
membranous  portion  often  produces  but  slight  hemorrhage.  The 
urethral  walls  are  elastic  and  retract  after  being  severed,  an  occur- 
rence that  would  naturally  tend  to  arrest  the  bleeding.  The  space 
between  the  torn  surfaces  becomes  blocked  by  a  blood-clot,  which 
plays  an  important  part  in  the  diminution  and  arrest  of  the  urethral 
hemorrhage. 

The  next  most  important  diagnostic  indication  of  the  existence 
of  a  rupture  of  the  urethra  is  interference  with  urination.  In  com- 
plete rupture  urination  is  arrested  at  once,  as  the  urine  that  escapes 
from  the  proximal  end  accumulates  in  the  wound  cavity  and  gives 
rise  to  urinary  infiltration.  In  incomplete  rupture  the  urine  may 
escape  first  through  the  natural  channel,  but  later  there  may  occur 
complete  occlusion,  due  to  para-urethral  infiltration.  If  the  rupture 
is  interstitial,  there  is  difficulty  of  micturition,  due  to  infiltration  of 
the  urethral  wall  causing  a  temporary  occlusion  of  the  lumen  of  the 
urethra.  In  about  75  per  cent,  of  all  cases  urine  retention  results 
from  obstruction  caused  by  the  formation  of  a  coagulum.  The 
perineal  swelling  that  invariably  attends  rupture  of  the  urethra  is 
caused  by  the  extravasation  of  either  blood  or  urine,  or,  what  is 
more  frequently  the  case,  by  both.  The  swelling  usually  involves, 
at  the  same  time,  the  scrotum.  The  primary  swelling  is  caused  by 
the  hemorrhage  and  increased  by  urine  extravasation.  A  gradual 
progressive  swelling,  which  makes  its  appearance  some  time  after 
the  receipt  of  the  injury,  is  always  due  to  extravasation  of  urine. 

Rupture  of  the  membranous  portion  of  the  urethra  alone  results 
in  extravasation  of  blood  and  urine  into  the  space  between  the  two 
layers  of  the  triangular  ligament.  In  such  cases  the  extravasation 
of  urine  can  not  extend  beyond  the  rami  of  the  pubis,  the  points  of 
attachment  of  the  two  layers,  without  laceration  of  either  of  them. 
The  swelling  in  such  instances  is  always  found  in  the  middle  line 
of  the  perineum.  If  the  rupture  occurs  anteriorly  to  the  ligament, 
it  is  always  attended  by  great  infiltration  of  the  scrotum,  and  in  neg- 
lected cases,  the  subsequent  infiltration  and  edema  extend  over  the 
anterior  surface  of  the  abdomen  as  far  as  the  umbilicus,  and  down- 
ward along  the  inner  aspect  of  the  thighs.  The  urinary  infiltration, 
unless  promptly  relieved  by  surgical  interference,  is  followed  by 
infection,  gangrene,  abscess  formation,  and  sepsis. 

Pain  at  the  site  of  rupture  and  tenderness  are  always  present, 
and  the  former  is  always  aggravated  during  attempts  at  urination. 
In  severe  cases  of  urethral  rupture  the  most  prominent  symptoms 
that  present  themselves  soon  after  the  accident  has  occurred  are 
complete  retention  of  urine,  urethral  hemorrhage,  and  perineal 
swelling. 

Prognosis. — The  prognosis  in  rupture  of  the  urethra  is  largely 
influenced  by  the  existence  of  serious  complications,  such  as  fracture 


TREATMENT.  305 

of  the  pelvis  and  the  promptness  and  efficiency  with  which  surgical 
aid  is  rendered.  The  danger  of  infection  must  always  be  remem- 
bered, and  if  infection  occurs,  it  is  very  difficult,  indeed,  to  predict 
the  gra\it\'  of  the  results  to  which  it  may  lead.  The  prognosis  of  a 
partial  is  always  more  favorable  than  that  of  a  complete  rupture  ; 
especialh'  is  this  the  case  if  the  mucous  membrane  has  not  been 
injured.  Kaufmann  estimates  t'he  mortality  of  all  cases  at  14  per 
cent.  Extensix'e  urinary  infiltration,  gangrene,  and  progressive 
phlegmonous  infiltration  are  some  of  the  early  complications  that 
alwa\-s  add  to  the  gravity  of  the  prognosis. 

Treatment. — The  fate  of  a  patient  the  subject  of  a  ruptured 
urethra,  either  of  traumatic  or  pathologic  origin,  depends  on  a  cor- 
rect early  diagnosis  and  on  the  receipt  of  prompt  surgical  aid. 
Every  general  practitioner  should  be  prepared  to  recognize  the 
accident  and  to  relieve  the  mechanical  difficulties  in  the  way  of 
spontaneous  urination,  as  tension  caused  by  the  extravasation  of 
blood  and  urine  is  one  of  the  principal  causes  of  more  remote  serious 
consequences.  Successful  catheterization  is  possible  only  in  cases 
in  which  the  rupture  is  incomplete.  In  the  complete  variety  the  use 
of  the  catheter  is  seldom,  if  ever,  attended  with  success,  but  serves, 
nevertheless,  as  a  means  of  diagnosis. 

The  first  tentative  efforts  in  this  direction  to  relieve  the  dis- 
tended bladder  should  be  made  with  a  soft  Nelaton  catheter,  of 
large  or  medium  size,  well  lubricated.  If  this  proves  unsuccessful,  a 
careful  effort  may  be  made  with  a  metallic  catheter,  as  with  cautious 
manipulation  of  this  instrument  clots  are  more  easily  displaced, 
and  entrance  into  the  bladder  thus  facilitated.  The  utmost  care 
must  be  exercised  in  the  employment  of  the  metallic  catheter,  as  it 
is  a  somewhat  dangerous  instrument  in  the  healthy  urethra  if  man- 
ipulated by  unskilled  hands,  and  in  the  torn  urethra  is  treacherous 
even  in  the  hands  of  an  expert.  No  force  vuist  be  used  in  its  intro- 
ductioji ;  it  should  find  its  waj'  largely  tJirongh  its  own  weight,  as 
otheriuise  additional  and  more  dangerous  false  passages  may  be  made. 

In  inserting  the  catheter  it  should  be  remembered  that  in  the 
great  majority  of  cases  the  wound  is  in  the  posterior  wall  of  the 
urethra,  in  the  region  of  the  bulbous  portion,  and  consequently  the 
roof  of  the  urethra  should  be  followed  instead  of,  as  is  only  too 
commonly  done,  its  floor.  The  anterior  wall  has  been  well  desig- 
nated by  Guyon  as  the  "surgical  wall."  If  there  is  any  doubt  as 
to  whether  the  bulbous  or  membranous  portion  is  torn,  it  is  ad- 
visable to  follow  the  anterior  wall  in  the  bulbous  portion,  and  the 
posterior  wall  in  the  membranous  portion,  as  here  the  anterior  wall 
is  most  frequently  torn.  Should  catheterization  prove  successful,  it 
is  advisable  to  retain  the  instrument  in  place  for  a  few  days,  as 
recommended  by  Duplay  and  others. 

Suprapubic  puncture  is  indicated  if  catheterization  fails  and  if  the 
physician  is  not  pre[)ared  to  [)erform  perineal  section  at  once.  It 
can  not  be  relied  upon  as  a  therapeutic  resource  any  further  than  as 
20 


3o6 


RUPTURE    OF    THE    URETHRA. 


a  palliative  measure  to  relieve  urine  retention  until  the  proper  prepa- 
rations can  be  made  for  the  radical  operation.  In  severe  cases 
perineal  section  must  be  made  with  as  little  loss  of  time  as  possible. 
Delay  in  performing  the  operation  is  attended  by  great  risks  follow- 


..at;f;:v«ati-j<t,--ii-j.iir^^ 


Fig.  175. — ^Wheelhouse' s  beaked  straight  staff. 

ing  the  consequences  of  blood  and  urine  extravasation  and  infection 
at  the  seat  of  injury.  Perineal  section  for  this  injury  was  advocated 
by  Chopart,  Desault,  and  Lallemand  in  the  beginning  of  the  last 
century,  and  is  now  universally  indorsed  as  the  operation  of  choice. 
Performed  under  the  necessary  aseptic  precautions,  the  mortality  of 
this  operation  has  been  reduced  to  less  than  10  per  cent.  External 
urethrotomy,  perineal  section,  boutonniere,  meet  the  most  urgent 
indications  in  the  treatment  of  a  urethra  ruptured  sufficiently  ex- 
tensively to  resist  successful 
catheterization.  The  opera- 
tion exposes  the  seat  of  in- 
jury to  direct  treatment, 
relieves  tension  by  furnish- 
ing a  free  escape  for  the 
products  of  extravasation,  and  secures  free  drainage  for  the  visceral 
wound,  thereby  minimizing  the  danger  of  infection.  The  operation 
must  be  performed  under  the  most  pedantic  aseptic  precautions, 
as  perineal  wounds  implicating  the  urethra  are  noted  for  their  great 
liability  to  infection. 

After  the  patient  is  fully  under  the  influence  of  the  anesthetic, 
he  is  placed  on  the  operating  table  in  the  lithotomy  position.  Two 
assistants  take  charge  of  the  lower  extremities,  the  knees  and  hips 
being  well  flexed  and  the  thighs  abducted.      If  there  is  any  lack 


Fig.  176. — Senn's  retractor. 


Fig.  177. — S)^ipe's  external  urethrotomy  staff. 


Fig.  178. — Volkmann's  four-prong  retractor. 

of  reliable  assistance,  it  is  well  to  tie  hand  and  foot  on  each  side 
together.  A  grooved  staff  or,  in  the  absence  of  such,  an  ordinary 
urethral  metallic  sound  is  next  introduced  into  the  bladder.  If 
however,  it  is  found  impossible  to  enter  the  bladder,  as  is  usually  the 


TREATMENT, 


307 


case  in  complete  ruptftre,  the  instrument  is  passed  down  to  the  seat 
of  injury.  The  staff  or  sound  so  introduced  serves  the  purpose  of 
a  reliable  guide  in  making  the  incision  down  to  the  urethra  and  the 
seat  of  rupture.  The  staff  or  sound  is  held  securely  by  an  assist- 
ant, who  rests  his  hand  on  the  symphysis  pubis.  With  the  left  hand 
the  same  assistant  elevates  the  scrotum.  The  operator  inserts  his 
left  index-finger  into  the  rectum,  and  makes  an  incision  in  the 
median  line,  through  the  skin  and  connective  tissue,  and  from  two 
to  three  inches  in  length,  which  extends  to  within  an  inch  of  the 
anal  margin.  Care  is  necessary  to  avoid  injuring  the  bulb  in  the 
upper  angle  of  the  wound.  If  the  bulb  has  not  been  injured  by  the 
trauma,  it  is  drawn  upward  with 
a  blunt  hook  or  the  finger  of  an 
assistant,  while  the  incision,  by 
successive  strokes  of  the  knife,  is 
deepened.  The  superficial  fascia 
and  transverse  perineal  muscles 
must  be  divided  before  the  ure- 
thra is  reached.  The  operator 
now  feels  for  the  groove  or  tip  of 
the  sound,  which  serves  him  as  a 
guide  to  the  seat  of  injury.  If 
the  rupture  of  the  urethra  is  com- 
plete, the  point  of  the  instrument 
will  be  felt  in  the  wound  between 
the  retracted  ends  of  the  urethra; 
if  incomplete,  the  floor  of  the  ure- 
thra is  freely  incised  in  order  to 
expose  the  lacerated  or  crushed 
part  of  the  urethra.  If  the  bulb 
has  been  injured,  the  removal  of 
the  masses  of  coagulated  blood 
will,  in  all  probability,  renew  the 
hemorrhage,  in  which  event  hemo- 
stasis  by  ligation,  direct  or  indi- 
rect, or  compression  by  forceps  or  tampon,  will  occupy  the  first 
attention  of  the  operator. 

The  recognition  of  the  crushed  urethra  is  often  a  matter  of  great 
difficulty,  but  is  usually  made  possible  by  the  careful  use  of  the 
staff  or  sound.  If  the  rupture  is  complete,  the  guide  in  the  urethra 
at  once  discloses  the  distal  end,  but  the  finding  of  the  proximal  end 
is  usually  very  difficult,  and  occasionally  impossible,  owing  to  the 
retraction  of  both  ends,  the  presence  of  coagula,  and  bruised  tissue. 
A  good  light,  patience  and  perseverance,  and  an  accurate  knowledge 
of  the  anatomic  relations  of  the  injured  parts  often  lead  to  success 
in  tlie  mo.st  difficult  cases.  I''orcing  urine  from  the  proximal  end 
by  compression  of  the  bladder  has  been  resorted  to  as  an  aid  in 
searching  for  the  opening,  but  its  value  in  rendering  such  assistance 


Fig.  179. — Anatomy  illustrating 
perineal  section :  a.  Bulb  of  urethra ; 
b,  pudic  artery  ;  c,  membranous  portion 
of  urethra  ;  d,  grooved  staff;  e,  prostate 
(Esmarch  and  Kowalzig). 


308  RUPTURE    OF    THE    URETHRA. 

has  been  greatly  overestimated.  If,  after  a  faithful  attempt,  the  sur- 
geon finds  it  impossible  to  secure  the  proximal  end,  a  tubular  drain 
the  thickness  of  the  little  finger  should  be  inserted  into  the  wound,  at 
a  point  behind  the  distal  end,  and  the  space  between  it  and  the  wound 
margins  packed  with  iodoform  gauze.  If  the  bladder  is  much  dis- 
tended, suprapubic  puncture  will  secure  the  necessary  immediate 
relief.  As  soon  as  the  bladder  recovers  its  tone  the  urine  is  expelled 
and  escapes  through  the  tubular  and  gauze  drain,  without  any  dan- 
ger of  extravasation  occurring,  and,  as  normal  urine  is  practically 
sterile,  without  much  additional  risk  of  wound  infection.  Later  it 
may  be  less  difficult  to  find  the  opening  during  the  time  the  urine 
escapes. 

Dr.  Brainard  was  the  first  one  to  suggest  retrograde  catheteri- 
zation through  a  suprapubic  opening  in  such  cases  for  the  purpose 
of  draining  the  bladder  through  the  proximal  part  of  the  urethra. 
This  practice  has  its  field  of  usefulness  in  desperate  cases,  as  has 
been  shown  by  a  number  of  successful  operations.  If  it  is  decided 
to  pursue  this  course,  the  retrograde  catheterization  should  be  done 

through  a  transverse  suprapubic  inci- 
sion (Fig.  174).  If  perineal  section  is 
performed  before  the  infiltrated  tissues 
have  become  infected,  the  urethral  and 
perineal  wounds  usually  heal  in  a  re- 
^.       o       „  ,        .    .„  markably    short    time,    and    the    urine 

tjg.    ISO. — bchematic   illus-  ^  ^  111 

tration  of  external  urethrotomy :  often    escapes    Spontaneously    through 

a.  Transverse  section ;  i,  longi-  the  natural  channel  in  a  few  days.      If 

tudinal  section;  C/  [/,  uretlira;  i^^fgction  has  occurred  at  the  time  the 
/^,  J^,   perineum    (Esmarch   and 

Kowalzig).  operation    was    performed     or    follows 

later,  free  drainage  is  required  until 
suppuration  is  under  control.  Stricture  of  the  urethra  as  a  remote 
result  of  rupture  is  only  to  be  feared  if  the  urethra  has  been  ex- 
tensively crushed,  as  under  ordinary  circumstances  the  resulting 
scar  tends  to  widen  the  elongated  and  injured  part  of  the  urethra, 
as  was  shown  many  years  ago  by  W.  Roser. 

It  has  been  suggested  that  in  complete  rupture  of  the  urethra 
an  attempt  should  be  made  to  restore  the  continuity  of  the  canal 
at  once  by  suturing.  Kaufmann  and  Hagler  have  demonstrated 
experimentally  that  primary  suture  is  not  followed  by  cicatricial 
contraction,  and  frequently  results  in  speedy  restoration  of  the 
urethral  channel.  The  results  of  these  experiments,  however,  only 
prove  that  so  ideal  a  healing  is  only  possible  in  incised  wounds, 
which  in  practice  are  the  exception,  contused  and  lacerated  wounds 
the  rule.  A  number  of  cases  of  successful  primary  suture  of  the 
torn  urethra  have  been  reported  by  Nogues,  Pearce  Gould,  Boisson, 
Rudolph  Frank,  Delorme,  and  others.  If  the  rupture  is  complete 
and  both  ends  can  be  found  and  brought  in  contact  without  tension, 
it  is  always  advisable  to  suture  with  catgut  at  least  the  upper  half 
segment  of  the  urethra,  and  drain  the  bladder  through  either  the 


FRACTURES.  3O9 

urethra  or  the  perineal  wound.  Bringing  a  portion  of  the  ends 
together  in  such  a  manner  prevents  undue  diastasis  and  does  fiot 
interfere  with  free  drainage  of  the  bladder  and  the  urethra.  More- 
over, it  can  not  fail  to  hasten  the  process  of  repair  and  to  improve 
the  functional  result.  Incised  wounds  of  the  urethra,  whether  acci- 
dental or  intentional,  should  always  be  sutured  if  the  seat  of  injury 
or  field  of  operation  is  aseptic  and  no  drainage  is  required.  Under 
no  circumstances  is  it  permissible  to  close  the  perineal  wound 
throughout,  as  drainage  of  the  wound  for  a  certain  length  of  time 
is  alwa)'s  a  necessity. 


CHAPTER  IX. 
FRACTURES» 


A  CONSIDERABLE  share  of  the  general  practitioner's  work  and 
source  of  income  consists  in  the  treatment  of  fractures.  There  is, 
perhaps,  no  other  department  of  surgery  in  which  good  common 
sense,  mechanical  skill,  and  a  thorough  knowledge  of  the  nature  of 
the  injur}'  are  more  important  in  securing  desirable  results  than  in 
the  treatment  of  fractures.  Success  means  the  building-up  of  a  good 
and  lasting  reputation  for  the  practitioner ;  failure  brings  reproach 
and  a  long-standing  source  of  humiliation.  Bad  results  following 
fractures  have  been  the  tombstones  that  have  marked  the  termina- 
tion of  an  otherwise  successful  professional  career  of  many  ill-fated, 
unlucky,  disappointed  practitioners.  It  is  not  always  possible  to 
prevent  unsatisfactory  results  by  the  employment  of  the  most 
modern  and  approved  methods  of  treatment,  but  it  is  a  source  of 
satisfaction  to  know  beforehand  when  to  expect  them,  and  to  recog- 
nize early  the  complications  that  justify  their  prediction.  Such 
knowledge,  properly  used,  is  an  invaluable  safeguard  against  assum- 
ing a  responsibility  so  often  unjustly  charged  against  the  practitioner 
in  cases  in  which  bad  results  are  inevitable,  and  owing  entirely  to 
the  nature  of  the  injury  and  not  to  any  defect  or  neglect  in  the 
treatment. 

It  is  very  evident  that  success  in  the  treatment  of  fractures  de- 
pends largely  on  an  early  and  a  correct  diagnosis.  The  most  flagrant 
mistakes  in  practice  follow  the  footsteps  of  an  erroneous  diagnosis. 
Forcible  attempts  to  reduce  a  supposed  dislocation  of  the  hip-joint 
in  fractures  of  the  neck  of  the  femur  are  followed  by  consequences 
alike  di.sastrous  to  the  patient  and  to  the  reputation  of  the  surgeon. 
The  same  can  be  said  of  fracture  of  the  anatomic  neck  of  the 
humerus  mistaken  for  and  treated  as  a  subcoracoid  dislocation  of 
the  head  of  the  humerus.  The  persistent  and  vicious  practice  of 
e.stablishing  the  existence  of  a  fracture  of  the  neck  of  the  femur 
by  searching  for  crepitus  as  the  most  reliable  evidence  of  the  pres- 


3IO  FRACTURES. 

ence  of  this  injury  has  only  too  often  resulted  in  converting  an 
impacted  into  a  nonimpacted  fracture,  and  in  doing  so,  removing 
the  anatomicomechanical  conditions  upon  which  so  much  depends 
in  securing  repair  by  bony  consolidation. 

A  correct  diagnosis  made,  the  result  of  the  treatment  is  deter- 
mined by  the  mechanical  skill  exercised  by  the  surgeon  and  the 
care  and  attention  with  which  he  conducts  the  after-treatment.  The 
most  learned  physicians  are  often  the  poorest  mechanics.  The 
plain  country  doctor,  endowed  with  a  liberal  amount  of  good 
common  sense  and  of  a  mechanical  turn  of  mind,  will  achieve 
success  in  difficult  cases  far  superior  to  that  of  some  of  the  most 
accomplished  physicians.  The  man  who  can  extemporize  an 
efficient  dressing  from  the  simplest  material  is  often  of  greater 
benefit  to  his  patients  than  the  one  whose  brain  is  crammed  and 
confused  with  an  immense  wealth  of  book  knowledge,  and  who  is 
fully  conversant  with  the  names  and  uses  of  innumerable  manufac- 
tured splints  devised  for  special  fractures  of  every  long  bone  in  the 
body. 

One  of  the  lessons  in  the  treatmejit  of  fractures  that  is  so  often 
forgotten  or  ignored  by  the  general  practitioner  is  that  the  treatment  of 
a  fracture  does  not  always  terminate  zvith  the  union  of  the  fragments 
by  bony  consolidation.  The  physician  who  takes  charge  of  a  fracture 
assumes  a  responsibility  that  terminates  only  with  the  restoration  of 
the  vtaximum  degree  of  function  compatible  with  the  nature  of  the 
injury.  This  period  of  time  necessarily  varies  zvith  the  location  and 
nature  of  the  injury  from  three  weeks  to  as  many  years.  Grave  mis- 
takes are  committed  daily  by  discharging  patients  with  the  removal 
of  the  splints  at  the  expiration  of  the  time  necessary  for  the  healing  of 
the  fracture  by  bony  consolidation.  Such  a  course  is  approved  of 
and  sanctioned  by  the  public,  which,  as  yet,  is  ignorant  of  the  many 
difficulties  that  must  be  met  in  restoring  function  after  the  fracture 
has  united.  These  remarks  apply  with  special  force  to  fractures  in 
close  proximity  to  or  involving  any  of  the  large  joints.  A  mutual 
understanding  between  physician  and  patient  in  the  management  of 
such  cases  must  be  effected  regarding  the  probable  ultimate  result 
and  the  time  and  efforts  necessary  to  reestablish  the  maximum 
obtainable  functional  result.  Many  fractured  limbs  are  made  com- 
paratively useless  by  premature  suspension  of  the  after-treatment, 
so  necessary  for  the  restoration  of  function. 

Frequency. — The  importance  of  fractures  becomes  apparent 
when  it  is  known  that  they  constitute,  as  has  been  shown  by 
extensive  statistics,  one-seventh  of  all  kinds  of  injuries  that  come 
under  the  care  of  the  general  practitioner.  Regarding  the  relative 
frequency  of  fractures,  the  statistics  of  the  London  Hospital, 
including  40,277  cases  from  1842  to  1874,  show  that  fractures  of 
the  upper  extremities  are  twice  as  frequent  as  are  those  of  the 
lower.  Fractures  of  the  long-  bones,  includincr  the  clavicle,  consti- 
tute  three-fourths  of  all  the  fractures,  while  fractures  of  the  skull 


PATHOLOGIC  OR  PSEUDOFRACTURE.  3II 

embrace  only  one  t\vent}'-fifth  of  all  cases.  The  bones  of  the 
forearm  furnish  the  largest  contingent  (i8  per  cent.),  and  the  tibia 
and  fibula  come  next  in  frequency,  followed  closely  by  the  ribs  and 
clavicle.  Fractures  of  the  scapula,  spine,  and  pelvis  occupy  the 
lowest  positions  in  the  scale  of  frequency. 

Men,  being  exposed  more  frequently  to  injuries  of  all  kinds 
than  women,  the  male  sex  predominates  in  the  statistics  of  frac- 
tures, the  proportion  being,  according  to  the  estimates  of  different 
authors,  about  3:1.  This  disproportion  is,  as  would  be  naturally 
expected,  most  marked  during  the  most  active  period  of  life — from 
twenty  to  forty  years  of  age.  In  both  sexes  fractures  occur  most 
frequently  from  the  second  to  the  fourth  dcccnnium,  a  time  of  life 
during  which  injuries  of  all  kinds  are  most  liable  to  occur.  In- 
complete fractures,  greenstick  fractures,  and  traumatic  epiphyseo- 
lysis  are  notably  frequent  injuries  of  childhood  and  young  adults, 
while  fractures  of  the  neck  of  the  femur  and  Colles'  fracture  are 
injuries  for  the  occurrence  of  which  senile  osteoporosis  furnishes  a 
marked  predisposing  cause.  Fractures  of  the  neck  of  the  femur  are 
rare  in  persons  under  fift}'  years  of  age,  and  the  increased  fragility 
of  the  bones  in  the  aged  constitutes  a  potent  influence  in  the  pro- 
duction of  Colles'  fracture  from  a  fall  upon  the  hand  in  persons  the 
subjects  of  senile  marasmus. 

In  children  fractures  occur  most  frequently  during  the  summer 
months  ;  in  the  aged,  usually  during  the  winter  months,  for  very 
obvious  reasons. 

Before  giving  the  classification  of  fractures  caused  by  a  trauma, 
it  is  necessary  to  refer  briefly  to  what  is  understood  and  meant  by  a 

Pathologic  or  Pseudofracture. — A  pseudo-  or  false  fracture  is 
a  solution  of  continuity  of  a  bone  which  occurs  independently  of  a 
traumatic  force  sufficient  to  fracture  a  bone  of  normal  structure  and 
resistance.  Such  injuries  have  been  described  as  spontaneous 
fractures,  an  erroneous  designation,  as  the  fractured  bone  is  always 
found  the  seat  of  disease,  the  break  being  caused  by  muscular  con- 
traction or  an  insignificant  injuiy.  The  terms  pseudofracture  and 
pathologic  fracture  arc  more  appropriate,  as  they  indicate  the  exis- 
tence of  an  antecedent  pathologic  condition  at  the  scat  of  solution 
of  continuity,  and  the  occurrence  of  the  latter  under  the  influence  of 
a  slight  or  nonappreciable  mechanical  cause.  Such  injuries  present 
to  the  physician  greater  pathologic  and  practical  importance  in  de- 
termining the  nature  and  origin  of  the  original  bone  affection  than 
the  occurrence  of  the  accident,  which  may  perhaps  furnish  the  first 
indication  of  the  antecedent  disease  of  the  bone.  Serious  mistakes  in 
the  treatment  of  fracture  have  been  made  by  concentrating  the  ener- 
gies on  the  mechanical  treatment  of  the  {xseudofracture  and  by  failure 
on  the  part  of  the  attendant  to  recognize  and  correctly  diagnosticate 
the  antecedent  affection  of  the  bone.  The  fracture,  if  we  use  the 
term  at  all,  in  such  instances  constitutes  only  a  compIicatif)n  of  the 
preexisting  bone  affection,  which    may  be   diffuse,  involving  many 


312  FRACTURES. 

or  all  the  bones,  or  limited  to  the  seat  of  the  pseudofracture,  as  is 
the  case  in  primary  or  metastatic  malignant  disease  or  localized 
inflammatory  affections  at  the  seat  of  injury.  The  conditions  that 
determine  the  fracture  are  such  as  to  justify  the  expression  patho- 
logic fractures,  as  the  injury  is  caused  by  pathologic  processes  that 
destroy  or  weaken  the  bones  to  an  extent  sufficient  to  produce  a 
severance  of  its  continuity  upon  the  slightest  injury. 

The  fragility  of  the  bone  (osteopsathyrosis,  fragilitas  ossium)  is 
a  symptomatic  condition  incident  to  several  affections  of  bone  found 
in  pathologic  or  pseudofractures. 

Predisposing  Causes. — In  the  enumeration  of  the  predisposing 
causes  of  pathologic  fractures  bone  atrophy  should  receive  first 
mention,  owing  to  the  frequency  with  which  it  is  found  as  the  sole 
pathologic  cause.  Atrophy  of  bone  as  a  diffuse  or  localized  condi- 
tion represents  different  pathologic  processes,  the  nature  of  many 
of  which  remains  unexplained  at  the  present  time.  Atrophy  of 
bone  does  not  necessarily  mean  diminution  in  its  volume  A  bone 
may  become  atrophic  without  diminution  of  its  size  by  the  gradual 
disappearance  of  its  organic  constituents,  which  increases  its  poros- 
ity and  diminishes  its  resistance,  resulting  in  a  condition  known  as 
osteoporosis.  The  most  conspicuous  gross  pathologic  conditions 
found  in  osteoporotic  bone  are  diminution  in  the  thickness  of  the 
compacta,  rarefaction  or  partial  or  complete  disappearance  of  the 
spongiosa,  and  dilatation  of  the  central  medullary  cavity  and  medul- 
lary spaces,  which  are  filled  with  yellow  medullary  tissue. 

One  of  the  most  frequent  causes  of  osteoporosis  and  the  accom- 
panying increased  fragility  of  bone  is  senile  marasmus.  Bones  thus 
affected  yield  to  slight  force,  and  in  some  cases  the  atrophy  reaches 
such  an  extent  that  a  fracture  may  occur  under  the  weight  of  the 
body  or  from  ordinary  muscular  action.  In  aged  men  and  women 
a  misstep  or  a  fall  upon  the  great  trochanter  is  often  sufficient  to 
produce  a  fracture  of  the  neck  of  the  femur.  General  osteoporosis 
is,  however,  not  a  constant  accompaniment  of  old  age,  as  it  is  occa- 
sionally found  in  persons  who  have  not  passed  middle  life,  and  is 
not  infrequently  absent  or  developed  only  to  a  slight  extent  in  per- 
sons of  far-advanced  age.  Gurlt  found  a  few  cases  of  pathologic 
fracture  in  persons  the  subjects  of  premature  senile  osteoporosis. 

Another  form  of  bone  atrophy,  limited  to  the  bones  of  an  ex- 
tremity or  part  of  an  extremity,  makes  its  appearance  in  conse- 
quence of  prolonged  enforced  rest,  and  is  then  called  inactivity  atro- 
phy. If  the  function  of  a  limb  remains  suspended  for  years  in 
consequence  of  paralysis  or  chronic  disease  of  bones  or  joints,  the 
bones  eventually  become  extremely  osteoporotic  and  fragile.  If 
the  causes  of  the  atrophy  set  in  during  early  childhood,  the  bones 
are  not  only  rendered  osteoporotic  and  fragile,  but  their  growth  is 
also  impaired  or  arrested,  great  shortening  of  the  limb  following  as 
an  inevitable  result.  If  the  causes  make  their  appearance  after  the 
completion  of  the  growth  of  the  skeleton,  the  bones  of  the  useless 


OSTEOMYELITIS.  3  I  3 

limb  undergo  eccentric  atrophy,  which  may  reach  such  a  degree  as 
to  serve  as  the  sole  cause  of  a  fracture  that  should  be  called  patho- 
logic. In  ankylosis  of  the  hip-joint  and  knee-joint  following  a  tuber- 
cular coxitis  during  childhood  the  bones  later  in  life  are  often  found 
so  fragile  that  they  fracture  or  bend  during  careful  efforts  made  to 
correct  an  existing  deformity  by  manual  force.  The  researches  of 
Julius  Wolf  have  shown  that  where  bone  tissue  is  not  in  static  use 
no  apposition  takes  place,  but  the  reverse  sets  in,  resorption,  which 
leads  to  osteoporosis  and  a  corresponding  loss  of  resistance. 

A  very  obscure  form  of  bone  atrophy  is  not  infrequently  ob- 
served, for  which  we  must  assume  a  trophoneurotic  origin.  Neu- 
rotic bone  atrophy  is  associated  with  some  forms  of  chronic 
inflammatory  and  degenerative  affections  of  the  brain  and  spinal 
cord.  Pathologic  fractures  have  been  repeatedly  observed  as  remote 
consequences  of  locomotor  ataxia.  Weir  Mitchell  was  the  first  one 
(1873)  ■^^'Iio  called  attention  to  pathologic  fractures  as  a  complica- 
tion of  this  disease.  This  subject  later  received  careful  and  extended 
study  by  Charcot,  and  the  number  of  well-authenticated  cases  of 
pathologic  fractures  occurring  during  the  advanced  stages  of  loco- 
motor ataxia  has  been  steadily  increasing  since  attention  has  been 
called  to  the  direct  connection  between  cause  and  effect. 

A  peculiar  form  of  great  fragility  of  the  long  bones,  cranium, 
and  spine  has  been  described  in  connection  with  progressive  general 
paralysis  of  cerebral  origin.  As  early  as  1842  Davey  found  six 
pathologic  fractures  in  a  postmortem  on  a  patient  who  died  from 
this  disease.  In  100  autopsies  Gudden  found  pathologic  fractures 
in  16,  and  in  three-fourths  of  these  cases  the  fracture  was  multiple. 
In  one  case  14,  and  in  another  t,^,  fractures  were  found  in  the  same 
subject. 

Another  form  of  fragility  of  bone  of  neurotic  origin  is  found  in 
connection  with,  and  as  a  consequence  of,  arrest  of  development  of 
the  cerebrospinal  centers.  Congenital  hydrocephalus  and  spina 
bifida  in  the  lumbar  region  are  often  productive  of  bone  atrophy  to 
so  great  a  degree  as  to  give  rise  to  pathologic  fracture.  Charcot 
regards  the  atrophy  of  bone  in  such  ca.ses  as  a  result  of  tropho- 
neurotic disturbances,  probably  caused  by  degeneration  of  the  ante- 
rior horns  of  the  gray  substance  of  the  spinal  cord.  Experimental 
researches  have  demonstrated  that  loss  of  innervation  following 
nerve  .section,  if  tiie  paralysis  continues  long  enough,  is  constantly 
followed  by  atrophy  (jr  rarefaction  of  the  bone  tissue  in  the  form 
of  eccentric  anostosis  and  substitution  by  the  deposition  of  fat. 
Chemic  analysis  of  tlie  atrophic  bone  shows  a  decided  diminution 
in  the  inorganic  constituents,  and  more  than  double  the  quantity  of 
organic  material,  this  great  increase  being  due  largely  to  the  depo- 
sition of  fat.  The  union  of  such  fractures  is  preceded  by  the 
formation  of  a  voluminous  callus. 

Osteomyelitis  as  a  source  of  pathc^logic  fractures  presents  itself 
in  two  forms — diffuse  and  circumscribed. 


314  FRACTURES. 

In  the  acute  diffuse  variety  of  osteomyelitis  pathologic  fracture 
may  occur  when  the  entire  thickness  of  the  shaft  of  a  long  bone  is 
destroyed  by  the  suppurative  inflammation,  and  the  formation  of  an 
involucrum  fails  to  take  place  or  is  retarded  by  extensive  or  com- 
plete destruction  of  the  periosteum.  Fortunately,  such  cases  are 
rare,  as  even  in  total  necrosis  of  the  shaft  of  a  long  bone  separation 
of  the  sequestrum  is  usually  preceded  by  the  formation  of  an 
involucrum  strong  enough  to  prevent  the  occurrence  of  such  an 
accident.  The  bone  gives  way  more  frequently  in  the  vicinity  of 
the  epiphyses  than  in  any  portion  of  the  shaft  (pathologic  epiphy- 
seolysis).  The  pseudofractures  occur  at  a  time  when  the  line  of 
demarcation  is  established  between  the  dead  and  the  livine  bone — 
seldom  before  the  sixth  week  after  the  commencement  of  the  acute 
attack.  I  have  observed  a  number  of  cases  of  pseudofracture 
complicating  acute  osteomyelitis,  and  resorted  to  the  usual  me- 
chanical treatment,  always  having  had  the  satisfaction  of  securing 
restoration  of  the  continuity  of  the  bone  by  the  formation  of  an 
involucrum  in  the  course  of  from  four  to  eight  weeks  after  the 
occurrence  of  the  accident. 

Epiphysitis  of  osteomyelitic  origin  is  another  cause  of  epiphy= 
seolysis.  The  primary  inflammation  and  the  subsequent  patho- 
logic separation  of  the  epiphysis  from  the  shaft  are  always  com- 
plicated by  inflammation  of  the  adjacent  joint,  a  fact  that  must 
be  taken  into  careful  consideration  in  the  selection  of  therapeutic 
resources.  Pathologic  fracture  of  the  epiphysis  resembles  very 
closely,  in  many  respects,  dislocation  of  the  adjacent  joint,  for 
which  it  is  not  infrequently  mistaken  and  treated.  In  acute  osteo- 
myelitis a  late  pathologic  fracture  may  occur  in  consequence  of  the 
imperfect  development  of  the  involucrum,  after  the  sequestrum  has 
become  separated,  and  is  then  due  to  fracture  of  the  neck  of  the 
involucrum. 

Circumscribed  osteomyelitis  figures  as  a  very  rare  cause  of 
pathologic  fracture  in  cases  in  which  the  resulting  abscess  destroys 
the  entire  thickness  of  the  shaft  of  the  bone,  or  weakens  it  suf- 
ficiently to  cause  it  to  yield  to  muscular  action  or  to  efforts  in  raising 
or  changing  the  position  of  the  limb.  A  number  of  such  cases  have 
been  recorded.  The  case  in  Verneuil's  clinic  furnishes  a  good  illus- 
tration :  A  boy  fifteen  years  of  age  suffered  from  an  attack  of  acute 
osteomyelitis  involving  the  lower  third  of  the  femur.  Death  from 
pyemia  followed  during  the  eighth  week.  Shortly  before  death 
fracture  occurred  at  the  seat  of  disease.  Autopsy  revealed,  in 
the  vicinity  of  the  fracture,  the  spongiosa  infiltrated  with  pus,  the 
bone  almost  entirely  destroyed  in  its  continuity,  and  infiltrated  with 
pus.     The  epiphyseal  cartilage  and  periosteum  were  intact. 

Tubercular  osteomyelitis  involving  the  epiphyseal  ends  of  the 
large  long  bones  occasionally  results  in  pathologic  epiphyseolysis. 
Pathologic  fracture  of  the  odontoid  process  of  the  axis  has  been 
known  to  produce  sudden  death  from  compression  of  the  cord  in 


RACHITIS. 


315 


tuberculosis  of  the  upper  cervical  vertebrae.  As  tuberculosis  seldom 
attacks  the  shafts  of  the  large  long  bones,  pathologic  fracture  from 
this  cause  is  almost  unknown  in  this  part.  Spontaneous  fracture 
from  tubercular  osteomyelitis  is  observed  most  frequently  in  the 
phalanges,  in  metacarpal  and  metatarsal  bones,  and  in  the  ribs. 

Rachitis  is  the  most  frequent  cause  of  pathologic  fracture  and 
bending  of  bones  in  infants  and  young  children.  Pathologically, 
this  disease  is  characterized  by  great  softening  of  the  bones,  in  which 
the  entire  skeleton  is  more  or  less  concerned.  The  rachitic  process 
consists  in  an  abnormal  development  of  the 
intermediary  cartilage  and  periosteum,  which 
results  in  the  growth  of  an  osteoid  in  place 
of  normal  bone  substance,  while  the  normal 
resorption  from  the  medullary  canal  con- 
tinues, gradually  reducing  in  thickness  and 
strength  the  normal  compacta.  The  normal 
static  evolution  of  the  cancellated  structure 
of  bone  suffers  at  the  same  time,  and  adds 
its  share  in  diminishing  the  resisting  power 
of  the  rachitic  bones.  During  the  acute 
stage  of  rachitis  incomplete  fractures,  infrac- 
tions, and  bending  of  the  bones  occur  more 
frequently  than  complete  fractures. 

Incomplete  fractures  are  almost  always 
found  only  on  the  concave  side,  where  the 
slight  fracturing  force  is  most  concentrated, 
while  on  the  convex  side  the  softened  bone 
tissue  and  thickened  periosteum  preserve 
the  continuity  of  the  bone.  Under  such 
circumstances  the  bones  curve  often  under 
the  weight  of  the  body  or  from  muscular 
contraction,  and  incomplete  fractures  result 
from  slight  falls  or  in  lifting  the  patient. 
The  spinal  column  yields  under  the  weight 
of  the  body  if  the  child  is  permitted  to  sit 
for  any  length  of  time  during  the  day,  a 
well-marked  long  posterior  curvature  devel- 
oping slowly  but  progressively. 

Complete  pathologic  fracture  of  rachitic 
bones  is    more    likely   to   occur  during  the 

latter  stages  of  the  di.sea.se  ;  that  is,  with  the  beginning  and  during 
the  healing  process.  Kven  in  such  cases  the  [jeriosteum  usually 
remains  intact.  The  femur  and  humerus  arc  most  frequently 
affected  by  complete  jKithologic  fracture  of  rachitic  origin. 

The  repair  of  fractures  in  rachitic  subjects  is  effected  by  the  .same 
materia]  as  the  rachitic  product — that  is,  osteoid  substance — during 
the  active  stages  of  the  disea.se,  but  with  the  disappearance  of  the 
disease,  either  spontaneously  or  through  the  intervention  of  medical 


Fig.  181. — Repair  of 
fracture  of  a  rachitic  hu- 
merus (longitudinal  sec- 
tion) :  a,  Compacta  .sur- 
rounding medullary  canal  ; 
b,  callus  mass  composed 
of  spongy  bone  tissue  ;  c, 
obliteration  of  medullary 
canal  by  displacement  of 
compacta  fractured  on  con- 
cave side,  and  by  callus 
formation,  which  is  most 
marked  on  concave  side 
(after  Gurlt). 


3l6  FRACTURES. 

treatment,  the  osteoid  callus  is  transformed  into  bone.  Callus  for- 
mation takes  place  only  in  the  fractured  part  of  the  bone,  hence  in 
incomplete  fractures  on  the  fractured  side  only,  which  is  almost 
invariably  on  the  convex  side  of  the  bone.  The  callus  is  often  so 
abundant  as  to  contribute  much  in  correcting  the  angular  deformity. 

Osteomalacia  constitutes,  in  the  adult,  a  somewhat  similar  pre- 
disposition to  pathologic  fracture  to  that  which  rachitis  does  in 
children.  Osteomalacia  is  a  disease  of  adults,  and  affects,  almost 
without  exception,  only  pregnant  and  puerperal  women. 

The  softening  and  fragility  of  the  bones  in  osteomalacia  are 
caused  by  the  substitution  of  osteoid  material  for  normal  bone 
tissue,  and  abnormal  proliferation  of  the  medullary  tissue,  with 
widening  of  the  medullary  spaces,  processes  that  eventually  remove 
the  entire  compacta,  leaving  the  softened  bone  ensheathed  by 
the  periosteal  envelop.  The  bones  in  advanced  cases  of  osteo- 
malacia bend  rather  than  fracture  spontaneously  or  under  the  in- 
fluence of  an  insignificant  trauma.  The  ribs  and  bones  of  the  ex- 
tremities are  most  frequently  the  seat  of  this  disease,  and  the 
fractures  usually  are  repaired  by  the  formation  of  a  bony  callus. 

Osteomalacia,  as  has  been  shown  by  Senator,  may  be  lim- 
ited to  one  bone  or  part  of  a  bone,  and  then  must  be  regarded  as  a 
local  process,  in  contradistinction  to  its  usual  clinical  manifestations. 
A  localized  form  of  osteomalacia  in  the  adult  has  been  described  by 
Volkmann,  affecting,  as  it  usually  does,  the  tibia  and  fibula,  occur- 
ring occasionally  as  a  bilateral  affection  and  followed  by  bending  of 
the  affected  bone  under  the  weight  of  the  body.  It  is  accompanied 
by  pain  and  tenderness  at  the  seat  of  osteoporosis,  and  has  been  de- 
scribed later  by  Czerny  as  osteitis  deformans.  Volkmann  found 
that  in  such  cases  the  compacta  over  a  limited  extent  is  transformed 
into  yielding  spongiosa. 

In  all  the  inflammatory  and  degenerative  affections  of  bone  here 
described  the  bone  and  periosteum  do  not  lose  their  regenerative 
capacity,  and  union  of  the  pseudofracture  or  pathologic  fracture  by 
bony  consolidation  is  not  only  possible,  but  probable.  Pseud- 
arthrosis  may  occur  in  cases  in  which  the  bone-producing  tissues 
are  extensively  destroyed,  as  occasionally  happens  in  suppurative 
osteomyelitis,  both  in  the  diffuse  and  circumscribed  varieties.  Such 
a  termination  can  not  be  expected  if  the  pathologic  fracture  is 
caused  by  either  a  primary  or  a  metastatic  malignant  tumor. 

Sarcoma,  the  primary  malignant  tumor  of  bone,  is  very  apt 
eventually  to  give  rise  to  a  pathologic  fracture  if  the  tumor  has  a 
central  origin.  In  central  myeloid  sarcoma  of  bone  the  preexisting 
bone  structure  is  gradually  destroyed  by  infiltration  and  pressure  until 
the  bone  gives  way  under  the  weight  of  the  body,  or  fractures  on  an 
attempt  to  move  the  limb.  Periosteal  sarcoma  seldom  gives  rise  to 
this  accident,  as  the  tumor  often  contains  a  framework  of  bone  tissue  ; 
infiltration  of  the  preexisting  normal  tissue  is  less  marked  than  in 
central  sarcoma,  and  pressure  as  an  element  in  the  causation  of  rare- 


CARCINOMA. 


317 


faction  and  atrophy  is  entirely  absent.  In  a  pathologic  fracture  of  a 
bone  in  connection  with  a  primary  malignant  tumor,  the  ver}'  occur- 
rence of  the  fracture  is  almost  positive  indication  of  the  central  loca- 
tion of  the  tumor.  Central  sarcoma  is  found  more  frequently  in  the 
epiphyseal  regions  of  the  long  bones  than  in  the  shaft,  while  the 
reverse  is  the  case  in  periosteal  sarcoma.  A  sarcoma  in  any  part 
of  the  bod}',  like  carcinoma,  may  give  rise  to  metastatic  tumors 
in  bone  and  a  resulting  pathologic  fracture  of  the  bone  thus 
affected. 

Carcinoma  of  bone  as  a  cause  of  pathologic  fracture  always 
presents  itself  as  a  sec- 
ondaiy  metastatic  tu- 
mor. Occasionally  the 
patient  is  ignorant  of  the 
existence  of  the  primary 
tumor,  and  after  a  va- 
riable period  of  local 
complaint,  Avhich  is  usu- 
ally attributed  to  rheu- 
matism and  treated  as 
such,  the  pseudofracture 
takes  place  and  is,  per- 
haps, the  first  thing  that 
calls  the  attention  of  the 
phx'sician  to  the  malig- 
nant affection  of  the 
bone  that  preceded  the 
accident.  I  remember 
a  case  of  this  kind  that 
occurred  many  years 
ago.  The  patient  was 
a  woman  seventy -five 
years  of  age,  who  had 
been  confined  to  bed 
for  a  number  of  weeks 
for  what  she  believed 
to  be  rheumatism  in 
her  left  hip-joint.  One 
morning  she  found  she 

had  lost  the  use  of  the  limb.  All  the  symptoms  pointed  to  a 
fracture  of  the  upper  part  of  the  femur.  Suspecting  the  nature  of 
the  cause  of  the  pathologic  fracture,  it  was  ascertained  that  a  small 
tumor  had  existed  in  the  left  mammary  gland  for  twenty  years. 
Examination  of  this  tumor  left  no  doubt  as  to  its  malignant  nature, 
a  diagnosis  fully  corroborated  by  a  chain  of  carcinomatous  glands 
in  the  corresponding  axillary  space. 

liruns  collected  79  cases  of  pathologic  fracture  caused  by  meta- 
static carcinoma,  and  found  that  in  59  the  primary  tumor  involved 


Fig.    182. — Pathologic  fracture  of   the  lower  eiul  of 
the  radius  caused  by  central  medullary  sarcoma. 


3  1 8  FRACTURES. 

the  mammary  gland.  According  to  Gurlt,  the  uterus  and  vagina 
rank  next  in  the  scale  of  frequency  as  the  seats  of  the  primary 
tumor.  The  femur  is  the  bone  affected  most  frequently  by  meta- 
static carcinoma,  and  of  the  bones  of  the  trunk,  the  vertebrae. 

Occasionally  the  metastasis  is  very  diffuse.  Thomsen  reports  a 
case  in  which  the  autopsy  on  a  patient  who  had  suffered  from  car- 
cinoma of  the  mamma  for  four  years  revealed  numerous  metastases 
in  almost  all  the  bones  of  the  skeleton,  which  had  gradually  led  to 
great  deformity  of  the  spine,  chest,  and  pelvis,  and  six  pathologic 
fractures  in  both  femora  and  the  left  humerus. 

In  very  rare  instances  pathologic  fracture  has  occurred  in  car- 
cinomatous patients  independently  of  metastasis  in  the  fractured 
bone,  and  must  then  be  explained  by  assuming  the  existence  of 
bone  atrophy  and  fragility,  caused  by  a  general  malnutrition  from 
the  effects  of  the  carcinoma.  A  pathologic  fracture  caused  by 
malignant  disease  is  seldom,  if  ever,  repaired  by  bony  consolidation. 
If  bony  union  does  take  place,  it  will  give  way  sooner  or  later  to 
extension  of  the  disease  to  the  callus. 

Enchondroma  and  cysts  sometimes  destroy  the  bone  tissue 
sufficiently  to  cause  a  pathologic  fracture.  Gross  collected  a  few 
cases  of  pathologic  fracture  resulting  from  enchondroma,  and  found 
that  this  accident  is  more  liable  to  occur  in  cases  of  central  than  of 
periosteal  tumors.  In  lo  cases  of  central  enchondroma  fracture 
occurred  twice,  while  in  63  cases  of  periosteal  sarcoma  it  was 
observed  only  three  times.  Froriep,  Nelaton,  and  Korte  have  each 
reported  a  case  of  pathologic  fracture  in  which  the  fracture  was 
caused  by  a  cyst. 

Echinococcus  cysts  of  bone  occupying  the  central  medullary 
cavity  of  the  long  bones  may  cause  a  degree  of  pressure  atrophy  of 
the  compacta  sufficient  to  cause  pathologic  fracture.  Bruns  col- 
lected 1 1  such  cases,  of  which  number  the  humerus  and  femur  were 
each  affected  four  times,  the  tibia  twice,  and  the  spinal  column 
once.  The  accident  occurred  usually  before  there  was  any  palpable 
enlargement  of  the  bone,  and  it  was  only  the  slight  degree  of  force 
which  produced  the  fracture  that  led  to  the  suspicion  of  antecedent 
central  disease  of  the  bone.  The  diagnosis,  as  a  rule,  was  made 
subsequently,  during  the  operation  for  the  resulting  pseudarthrosis. 

Syphilis  is  very  seldom  the  cause  of  pseudofracture,  considering 
the  great  prevalence  of  this  affection.  Gurlt  was  able  to  collect  only 
20  cases  of  pathologic  fracture  from  the  old  literature  in  which  a 
direct  causative  relationship  could  be  traced  between  tertiary  syphilis 
and  pseudofracture.  In  most  of  these  cases  the  humerus  and 
clavicle  were  the  seat  of  fracture,  and  the  injury  was  usually  pro- 
duced by  an  attempt  to  use  the  arm  in  throwing  or  by  leaning  upon 
it.  Fragility  of  bone  has  been  attributed  to  the  prolonged  use  of 
mercurial  preparations,  but  this  view  is  not  supported  by  facts.  In 
the  few  cases  in  which  syphilis  does  figure  as  a  cause  of  pathologic 
fracture  the  abnormal  localized  or  diffuse  fragility  of  the  bone  was 


SCORBUTUS.  3  I  9 

caused  by  tertiary  lesions  of  the  bone  itself.  Gummatous  perioste- 
itis  and  osteomyelitis  may  eventually  destroy  the  entire  thickness 
of  the  part  of  the  bone  affected. 

In  children  hereditaiy  syphilis  not  infrequently  leads  to  patho- 
logic epiph\'seolysis.  The  softening  of  the  bone  occurs  in  the 
epiph\'seal  line,  where  the  osteoporotic  bone  contains,  in  the  dilated 
medullary  spaces,  a  peculiar  gelatinous  material.  Pathologic 
fractures  from  this  cause  may  occur  during  intra-uterine  life. 

Scorbutus  occasionally  gives  rise  to  localized  bone  affections 
which  may  cause  a  pathologic  fracture.  Scorbutic  affections  of 
bone  sufficiently  severe  to  destroy  its  continuity  are  found  most 
frequently  at  the  junction  of  the  ribs  with  their  cartilages.  In 
advanced  cases  of  scurvy  complicated  by  osteochondritis  and 
periosteitis  of  the  ribs  these  affections  are  very  apt  to  cause  multiple 
pathologic  fractures. 

The  causes  of  pathologic  fracture  here  enumerated,  many  as 
they  are,  do  not  explain  all  cases.  In  some  instances  the  great 
osteoporosity  and  fragility  of  bone  presents  itself  as  a  hereditary 
affection  for  which  no  adequate  or  satisfactory  explanation  can  be 
given.  The  strength  and  resisting  power  of  bone  are  subject  to 
many  variations.  Some  persons  otherwi.se  apparently  in  good 
health  inherit  a  strong  predisposition  to  fractures.  A  large  number 
of  well-authenticated  cases  of  this  kind  have  been  recorded.  A 
number  of  persons  of  the  same  age  and  weight  may  meet  with 
similar  accidents  ;  in  some  a  fracture  will  occur,  while  the  re- 
mainder escape  with  a  sprain  or  an  insignificant  brui.se.  Hamilton 
treated  a  man  fifty-three  years  of  age  for  eleven  fractures  and  two 
dislocations,  in  whose  family  there  existed  a  strong  predisposition 
to  fractures.  Blanchard  observed  the  case  of  a  girl  twelve  and 
one-half  years  of  age  who  had,  since  the  age  of  two  years,  sustained 
forty-one  fractures  from  the  slightest  cau.ses,  among  them  fourteen 
of  the  right  and  eleven  of  the  left  leg.  Among  this  class  of  cases 
of  pathologic  fractures  we  must  include  all  those  in  which  the  usual 
cau.ses  of  pseudofracture,  as  previously  given,  can  be  eliminated. 
It  is  probable,  too,  that  additional  research  and  oKservations  will  in 
the  future,  as  they  have  done  in  the  past,  reduce  the  number  more 
and  more  by  the  discovery  of  new  causes  and  conditions  that  will 
throw  more  liglit  on  the  presenile  osteoporosis  and  fragility  of  bone. 

In  ascertaining  the  exi.stence  and  location  of  a  pathologic  frac- 
ture, the  practitioner  must  not  rely  on  crepitus  in  conducting  the 
examination,  as  by  doing  so  much  harm  may  be  inflicted,  and  the 
information  thus  gained  may  lead  to  erroneous  conclusions.  The 
pathologic  conditions  of  the  bone  are  often  such  as  to  exclude  the 
possibility  of  eliciting  crepitus.  Loss  of  function,  the  false  point 
of  motion,  malposition  of  the  limb,  and,  if  there  is  longitudinal 
displacement,  comparative  measurements,  must  be  relied  upon  in 
recognizing  and  locating  the  accident.  Pain  and  tenderness  are 
of  slighter  importance,  from  a  diagnostic  .standpoint,  in  pathologic 


320 


FRACTURES. 


than  in  traumatic  fractures.  The  pathologic  fracture  is  usually- 
transverse,  or  nearly  so,  and  longitudinal  displacement  to  any  con- 
siderable extent  is  rare,  while  angular  deformity  is  almost  constantly 
found  sooner  or  later.  In  spontaneous  fracture  resulting  from 
malignant  disease  a  swelling  at  the  seat  of  fracture  can  be  detected 
more  frequently  in  primary  than  in  metastatic  tumors  of  the  bone. 
Except  in  fractures  caused  by  malignant  disease,  the  prognosis 
concerning  the  repair  of  the  injury  is  favorable.  In  many  cases  the 
process  of  repair  appears  to  be  favored  by  the  osteoporotic  condition 
of  the  bone  caused  by  the  general  or  localized  affection.  Speedy 
and  often  massive  callus  production  is  observed.  The  mechanical 
treatment  of  such  fractures  is  attended  by  no  special  difficulties,  as 
the  tendency  to  displacement  is  less  manifest  than  in  traumatic 
fractures.  As  the  trauma  that  completes  the  fracture  is  always 
slight,  little  or  no  additional  swelling  follows  the  injury,  and  it  is 
safe  and  advisable  to  immobilize  the  limb  at  once  by  a  plastic  or 
circular  plaster-of- Paris  splint.  The  general  treatment  must  be  con- 
ducted according  to  the  nature  of  the  bone  affection  and  the  general 
condition  of  the  patient. 

Classification  of  Fractures. — A  correct  diagnosis,  a  reliable 
prognosis,  and  the  proper  treatment  of  traumatic  fractures  must  be 

based    on    a    rational   ana- 
tomic classification. 

Incomplete  Fracture. 
— A  fracture  is  said  to  be 
incomplete  when  a  bone  is 
only  partly  broken.  As 
compared  with  complete 
fractures,  this  accident  is 
very  rare.  Anatomically  it 
presents  itself  in  the  form 
of  a  fissure,  infraction,  de- 
pression, or  in  separation 
of  a  fragment  of  bone  or 
an  apophysis. 

A  fissure  is  a  linear 
fracture  and  occurs  either 
as  an  isolated  injury  or  in 
connection  with  other  fractures.  Straight  and  spiral  fissures  of  the 
long  bones  have  been  observed  in  which  the  continuity  of  the 
bone  was  preserved.  Such  fractures  are  exceedingly  rare,  and  a 
correct  diagnosis  is  seldom  made.  Linear  fractures  or  fissures 
occur  more  frequently  in  connection  with  complete  fractures,  more 
especially  in  fractures  of  the  skull  and  in  gunshot  fractures  of  the 
long  bones.  In  the  latter  case,  if  the  fracture  is  near  one  of  the 
epiphyses,  the  fissure  frequently  extends  into  the  adjacent  joint. 

An  infractioji  is  an  incomplete  fracture,  and  is  represented  by  the 
so-called  greenstick  fracture.      It  is  met  most  frequently  in  children 


Fig.  183. — Isolated  fissure  of  the  skull,  caused 
by  a  fall  upon  the  head.  The  fissure  crosses  the 
coronary  fissure,  and  involves  the  occipital,  parie- 
tal, and  frontal  bones  (after  Bruns). 


INCOMPLETE    FRACTURE. 


321 


and  in  persons  the  subjects  of  softening  of  bone.  If  one  of  the 
long  bones  is  the  seat  of  an  infraction,  the  periosteal  envelop  often 
remains  intact,  the  bone  on  the  fractured  side  is  crushed  to  a  greater 
or  less  extent,  while  the  part  of  the  shaft  on  the  opposite  side, 
owing  to  its  great  elasticity,  yields,  permitting  a  certain  degree  of 
angular  deformity,  which  is  always  present  and  which  clinically  con- 
stitutes the  most  important  diagnostic  criterion.  A  partial  fracture 
of  a  long  bone  b\'  infraction  is  characterized  by  bending  and  more 
or  less  separation  on  the  fractured  side.  The  partial  fracture 
al\va}-s  corresponds  with  the  convex  side  of  the  angular  deformity. 
If  the  angular  deformity  is  slight,  the  accident 
is  very  likely  to  be  overlooked. 

Konig  has  described  partial  fracture  of  the 
neck  of  the  femur  in  the  aged,  but  it  is  some- 
what doubtful   if  such  an   injury  is   compatible 


Fig.  184. — Longi- 
tudinal fissure  of  the  hu- 
merus (after  Froriepj. 


Fig.  185. — Spiral  fis- 
sure of  the  tibia,  seen  from 
behind  (after  Bruns). 


Fig.  186. — Infraction  of 
the  radius  in  a  child  twelve 
years  of  age  (after  Vidal). 


with  the  senile  osteoporosis  and  fragility,  and  it  is  more  than 
probable  that  in  cases  thus  interpreted  the  injury  consisted  of  a 
complete  fracture  with  impaction.  Partial  fractures  clinically  char- 
acterized by  depression  are  represented  in  a  most  typical  manner  by 
fractures  of  the  external  table  of  the  cranial  bones,  although  they 
can  occur  in  any  other  bone  in  which  a  thin  compacta  is  supported 
by  a  bed  of  spongiosa.  In  rare  cases  the  internal  table  of  the  skull 
yields  to  the  direct  application  offeree,  the  external  table  remaining 
intact,  thus  constituting  another  variety  of  incomplete  fracture.  In 
consequence  of  direct  application  of  force  a  fragment  of  bone  can  be 
detached,  or,  as  the  result  of  a  traction  injury,  the  tendinous  inser- 
tion of  a  bone  or  an  apophysis  may  become  .separated,  producing 
another  anatomic  form  of  incomplete  fracture. 

(')\ving  to  the  slight  degree  or  total  absence  of  deformity,  incom- 
plete fractures  are  seldom  recognized.      The  possibility  of  such  an 
21 


322 


FRACTURES. 


r./V>^-^ 


occurrence  should  always  be  borne  in  mind  in  connection  with 
injuries  that  are  likely  to  produce  such  fractures,  and,  if  need 
be,  repeated  careful  examinations  should  be  made  to  ascertain 
their  existence.      In  doubtful   cases  the  patient   should   be    given 

the  benefit  of  the  doubt,  and  the  in- 
jury should  be  treated  as  a  frac- 
ture. The  formation  of  a  callus  in 
the  usual  course  of  time  in  suspected 
cases  will  often  enable  us  to  make  a 
positive  diagnosis  at  a  time  necessary 
to  obtain  the  desired  functional  result 
by  appropriate  treatment.  In  sus- 
pected fracture  of  the  internal  table 
of  the  skull  the  X-ray  will  furnish  the 
lacking  diagnostic  information.  In 
children  serious  functional  disturb- 
ances following  injuries  of  any  of  the 
extremities  should  always  arouse  sus- 
picion of  an  incomplete  fracture,  and 
should  remind  the  physician  of  the  ne- 
cessity of  making  a  most  scrutinizing 
examination,  and  in  doubtful  cases  of 
repeating  the  same  every  few  days. 
Conspicuous  deformities  and  serious 
functional  impairment  of  the  injured 
limb  have  often  been  the  consequence 
of  a  lack  of  care  and  attention  in  such 
cases. 
Subcutaneous  Simple  Fractures. — The  simple  subcutaneous  or 
closed  fracture  is  by  far  the  most  frequent  injury  of  bone  that  comes 
under  the  care  of  the  general  practitioner.  The  long  bones  are  most 
frequently  fractured,  and  the  description  of  the  injury  will  apply  to 
them,  as  fractures  of  the  skull  and  compound  fractures  are  dis- 
cussed elsewhere. 

The  line  of  fracture,  according  to  its  direction  and  shape,  is 
described  as  transverse,  oblique,  longitudinal,  dentate,  and  Y-shaped. 
Intra-articular  fractures  are  always 
transverse,  or  nearly  so.  Fractures 
near  the  epiphyses  are  more  likely 
to  be  transverse  than  fractures  of 
the  shaft.  In  infants  and  children 
transverse  fractures  of  the  shaft  are 
common.  In  transverse  fractures 
shortening    is    not    present    if  the 

fragments  do  not  overlap  each  other.  Angularity  at  the  seat  of 
fracture  is  the  most  constant  deformity  and  should  receive  the 
most  careful  attention  in  the  mechanical  treatment  of  the  injury. 
In  the  adult  the  line  of  fracture   through  the  shaft  of  any  of  the 


Fig.  187. — Infraction  of  the 
neck  of  the  femur,  caused  by  a 
fall  from  a  height,  which  at  the 
same  time  fractured  the  shaft  of 
the  same  bone  in  its  middle  and 
the  spine.  Death  after  eighteen 
days  (after  Mussey). 


Fig, 


— Dentate  transverse  fracture 
of  a  rib  (Bruns). 


SUBCUTANEOUS    SIMPLE    FRACTURES. 


323 


long  bones  is  nearl}-  always  more  or  less  oblique.  The  degree  of 
obliquity  is  determined  to  some  extent  by  the  compactness  of  the 
bone  and  the  manner  in  which  the  injury  was  inflicted.  As  a  rule, 
it  may  be  said  the  harder 
the  bone,  the  more  ob- 
hque  the  line  of  fracture. 
Fractures  resulting  from 
indirect  force  as  a  rule 
are  more  oblique  than 
fractures  caused  by  di- 
rect violence.  The  de- 
gree of  obliquity  has 
some  influence  in  deter- 
mining the  amount  of 
shortenino;.  Long-jtud- 
inal  displacement  of  the 
fragments  is  favored  by 
the  degree  of  obliquity 
of  the  line  of  fracture, 
and  marked  shortening- 
soon  after  the  accident 
has  occurred  is  one  of 
the  clinical  witnesses 
suggestive  of  the  oblique 
direction  of  the  line  of 
fracture. 

Longitudinal  fracture  of  the  long  bones  has  already  been  re- 
ferred to  under  incomplete  fractures.  Although  a  very  rare  acci- 
dent, it  should  be  carefully  looked  for  in  injuries  to  the  shaft  of  the 


Fig.  189. — Trans- 
verse fracture  of  the 
shaft  of  the  tibia, 
caused  by  passage  of 
a  wagon-wheel  over 
the  limb  (Bruns). 


Fig,  190. — Oblique  frac- 
ture of  the  femur  ;  fractured 
ends  in  the  form  of  the 
mouthpiece  of  a  clarinet 
(Bnms). 


Fig.    191. — T-shaped  fracture  of  the       Fig.    I92. — Lines  of  fracture  of  the  upper 
condyles  of  the    femur,  caused    by  a   fall  extremity  of  the  femur, 

upon  the  knee  (after  IJruns). 


324 


FRACTURES. 


long  bones  sufficient  in  intensity  to  produce  a  fracture,  yet  unac- 
companied by  indications  that  point  to  the  existence  of  a  transverse 
or  oblique  fracture.  If  the  fractured  ends  are  dentate,  interlocking 
and  partial  immobilization  of  the  fragments  are  apt  to  occur,  in 
which  event  crepitus  and  shortening  are  absent  and  the  mutual 
coaptation  between  the  fractured  surfaces  by  the  spicula  of  bone 
serves  a  useful  purpose  in  the  mechanical  treatment  of  the  fracture. 
Such  fractures  are  usually  more  or  less  transverse,  and  occur  most 
frequently  near  the  articular  extremities  of  the  long  bones. 

The  typical  Y-  and  T-shaped  fractures  are  found  in  the  lower 
end  of  the  femur  and  humerus,  and  consist  of  a  fracture  of  the  con- 


Fig.  193. — Y-shaped  fractures  of  the  condyles  of  the  humerus. 


dyles  above  the  joint,  with  a  line  of  fracture  between  them  which 
extends  into  the  joint.  The  widening  of  the  bone  by  the  diastasis 
between  the  condyles  and  the  preternatural  mobility  at  the  seat  of 
injury  are  the  two  symptoms  that  serve  to  distinguish  this  injury 
from  a  dislocation.  In  reference  to  the  location  of  fractures  of  the 
long  bones  we  speak  of  fractures  of  the  shaft  and  of  the  neck,  inter- 
condyloid  fractures,  separation  of  an  epiphysis,  and  detachment  of 
an  apophysis.  Fractures  of  the  shaft  predominate  in  frequency  and 
are  usually  attended  by  marked  deformity,  and  when  oblique,  short- 
ening is  almost  invariably  present.  Fractures  of  the  neck  of  the 
femur  and   humerus   are   divided,   anatomically,  according  to   the 


SUBCUTANEOUS    SIMPLE    FRACTURES.  32$ 

relation  the  line  of  fracture  bears  to  the  capsular  ligament,  into 
intracapsular,  extracapsular,  and,  if  the  fracture  intersects  the  cap- 
sular ligament,  into  partly  extracapsular  and  partly  intracapsular. 

An  absolute  anatomic  diagnosis  can  seldom  be  made.  A  primary 
para-articular  swelling  and  decided  shortening  of  the  limb  soon  after 
the  occurrence  of  the  accident  suggest  an  extracapsular  fracture, 
while  the  opposite  conditions  would  speak  in  favor  of  a  fracture 
within  the  boundaries  of  the  capsule.  More  frequently,  however, 
the  line  of  fracture  passes  through  the  capsule,  when  the  symptoms 
are  modified  by  the  concomitant  injuries  of  the  soft  tissues. 

Intercondyloid  fractures  of  the  humerus  and  femur  always  im- 
plicate the  adjacent  joint,  a  complication  which  is  clinically  charac- 
terized by  the  appearance  of  a  swelling  in  the  joint,  caused  pri- 
marily by  intra-articular  extravasation  of  blood,  aggravated  later 
by  the  products  of  a  catarrhal  synovitis. 

Any  of  the  apophyses  may  become  separated  by  the  applica- 
tion of  direct  force  or  by  muscular  traction,  and  in  either  event  one 
point  of  anchorage  of  one  or  more  tendons  or  muscles  is  lost,  the 
accident  resulting  in  functional  disturbances  that  point  to  the  loca- 
tion and  extent  of  the  injury.  The  diastasis  between  the  fragments 
varies  according  to  the  extent  of  injury  of  the  soft  tissues  and  the 
degree  of  isolation  of  the  point  of  tendon  or  muscle  insertion. 

A  traumatic  epiplu'seoh'sis  consists  of  a  transverse  fracture 
through  or  near  an  intermediate  cartilage,  and  is  an  accident  that 
only  occurs  in  children  and  young  adults — that  is,  in  persons  during 
the  bone-growing  period  of  life.  The  close  proximity  of  the  frac- 
ture to  joints  often  results  in  conditions  that  render  it  difficult 
to  make  a  differential  diagnosis  between  fracture  and  dislocation. 
Epiphyseolysis  never  gives  rise  to  the  same  degree  of  immobility 
of  the  injured  limb  as  dislocation,  and  unless  the  epiphysis  is  suffi- 
ciently displaced  to  permit  of  longitudinal  displacement,  shortening 
of  the  limb  does  not  occur,  and  elongation  of  the  limb  is  never  ob- 
served. Comparati\'e  measurements  are  therefore  of  the  greatest 
importance  in  differentiating  between  a  traumatic  epiphyseolysis 
and  a  dislocation. 

An  intra-articular  fracture  is  one  in  which  the  line  of  fracture  is 
within  the  limits  of  the  capsular  ligaments.  This  anatomic  variety 
of  fractures  is  limited  to  the  neck  of  the  femur,  humerus,  and 
radius. 

A  multiple  fracture  is  one  in  which  the  same  bone  is  fractured 
in  different  places,  or  where  the  same  injury  results  in  fracture  of 
different  bones. 

A  compound  fracture  consists  of  a  fracture  of  any  bone,  com- 
plicated by  an  injury  of  the  soft  tissues,  which  establishes  an  avenue 
between  the  surface  of  the  skin  or  any  of  the  mucous  membranes 
and  the  .seat  of  fracture. 

A  pathologic  fracture  is  the  result  of  an  existing  disease  of 
the  bone  which  gives  rise  to  a  solution  of  continuity  without  or 


326 


FRACTURES. 


with  but  insignificant  trauma.  The  pathologic  conditions  that  may 
bring  about  such  a  condition  have  already  been  enumerated  and 
described. 

A  fracture  deserves  the  qualifying  term  complicated  if  the  frac- 


Fig.  194. — Traumatic  epiphyseolysis  of  upper  end  of  the  humerus  (after  Oscar  Wolff). 
a  b 


Fig.    195. — Traumatic  epiphyseolysis  of  lower  end  of  the  femur:   a.  Lateral  illumina- 
tion ;  b,  anteroposterior  illumination  (after  Oscar  Wolff). 


ture  is  accompanied  by  an  injury  to  any  of  the  large  blood-vessels 
or  nerve -trunks. 

A  fracture  is  said  to  be  comminuted  if  the  bone  is  crushed  or 
splintered  into  a  number  of  fragments  at  the  seat  of  fracture. 

Causes  of  Fracture. — The  predisposing  causes  of  fracture  con- 


MECHANISM    OF    THE    EXCITING    CAUSES    OF    FRACTURES.  327 

sist  of  congenital  or  acquired  textural  changes  in  the  bone  which 
diminish  its  power  of  resistance.  The  physiologic  causes  include 
structural  and  textural  conditions  that  weaken  the  bone,  but  not  to 
a  sufficient  degree  to  give  rise  to  a  pathologic  fracture.  These 
causes  include  age,  heredity,  inactivit}^  atrophy,  and  the  structure 
and  function  of  the  long  bones.  The  two  extremes,  youth  and  old 
age,  predispose  the  bones  to  fracture.  The  softness  of  the  bones 
in  children  and  the  increased  fragility  of  the  bones  of  the  aged 
are  well-recognized  predisposing  causes  of  fracture.  Trauma  in 
children  and  the  aged  is  more  likely  to  result  in  a  fracture  than  a 
dislocation.  Dislocations  occur  most  frequently  during  the  active 
period  of  life,  after  the  bones  have  become  fully  developed  and 
before  senile  osteoporosis  sets  in.  Traumatic  epiphyseolysis  is  an 
injuiy  of  childhood  and  young  adolescents,  and  fracture  of  the  ana- 
tomic neck  of  the  femur  and  humerus  is  seldom  seen  in  persons  less 
than  fifty  years  of  age. 

Heredity  as  a  predisposing  cause  of  fracture  means  a  congenital 
defect  in  the  development  of  bone  to  its  average  physiologic  stand- 
ard. Some  individuals,  families,  and  successive  generations  are 
predisposed  to  fractures  in  consequence  of  an  inborn  weakness  of 
the  bones.  A  vigorous  muscular  development  does  not  always 
imply  that  the  bones  have  reached  a  similar  degree  of  perfection 
of  growth  and  resistance.  In  a  case  of  suspected  fracture  caused 
by  a  force  that,  under  ordinary  circumstances,  would  not  cause  a 
fracture,  it  is  well  enough  to  investigate  the  personal  and  family 
history  carefully,  to  ascertain  the  possible  existence  of  a  hereditary 
predisposition  to  fracture  before  the  existence  of  a  fracture  is  ex- 
cluded, owing  to  a  supposed  inadequacy  of  the  injuring  force. 

Prolonged  inactivity'  is  constantly  followed  by  bone  atrophy, 
which  becomes  a  predisposing  cause  of  fractures  in  proportion  to  the 
degree  of  atrophy.  The  most  familiar  illustrations  of  inactivity 
atrophy  are  furnished  by  permanent  paralysis  sustained  during 
childhood,  and  ankylosis  following  joint  tuberculosis.  Manual 
redressement  by  moderate  force,  made  for  the  purpose  of  correcting 
deformities,  under  such  circumstances  has  not  infrequently  resulted 
in  fracture. 

By  their  structure  and  function  the  long  bones  are  predisposed 
to  fracture.  The  attachment  of  numerous  strong  muscles,  the  long 
leverage,  and  the  frequency  with  which  thcy^  are  exposed  to  direct 
and  indirect  injuries  explain  fully  why  the  long  bones  furnish  the 
large  percentage  of  fractures. 

The  pathologic  causes  of  fractures  have  been  already  referred 
to,  and  among  them  the  most  important  are  sarcoma,  carcinoma, 
rachitis,  osteomalacia,  osteomyelitis,  paralysis  of  central  origin, 
syphilis,  scorbutus,  and  echinococcus  and  other  cysts. 

Mechanism  of  the  Exciting  Causes  of  Fractures. — The 
occurrence  of  a  traumatic  fracture  presupposes  tlie  action  of  an 
adequate  mechanical  cau.se  to  cjvercome  the  resistance  of  the  bone 


328 


FRACTURES. 


broken.  The  accident  is  produced  either  by  violence  from  without, 
by  direct  or  indirect  apphcation  of  force,  or  by  traction  force  from 
within — that  is,  by  muscular  contraction. 

External  Violence. — By  far  the  greatest  number  of  fractures 
are  produced  by  external  violence.  The  mechanism  of  the  fractur- 
ing force  is  variable,  but  in  all  cases  it  must  suffice  in  overcoming 
the  elasticity  and  resisting  power  of  the  broken  bone.  The  trauma 
fractures  the  bone  either  by  pressure  or  traction,  or  by  a  combina- 
tion of  these  two  mechanical  forces.  As  was  ascertained  by  the  in- 
genious experiments  made  by  Rauber  and  quoted  by  Bruns,  a 
much  greater  force  is  required  to  fracture  a  long  bone  from  com- 
pression than  if  the  bone  is  bent  at  the  same  time,  thus  combining 

pressure    with     traction. 

i  '  ii /...iM  Fracture     of     a      bone 

caused  by  bending  will 
always  take  place  at  a 
point  where  the  curve  is 
most  marked,  and  con- 
sequently where  tension 
is  greatest.  If  both  ar- 
ticular ends  are  sup- 
ported, the  fracture  takes 
place  in  the  middle  ;  if 
only  one  end  is  fixed, 
immediately  in  front  of 
the  point  of  fixation. 
For  the  same  reason  the 
fracture  always  begins 
on  the  convex  side  of 
the  bend,  as  has  been 
demonstrated  so  con- 
clusively by  clinical  ob- 
servations and,  likewise, 
by  the  experiments  of 
Bruns  and  Messerer. 
all  cases  of  fracture 
suiting  from  forces  that  cause  a  bending  of  the  bone  the  line 
fracture  is  transverse  for  an  indefinite  distance,  when  it  forks  in 
both  directions,  including  between  the  branches  a  detached  frag- 
ment of  bone  if  both  branches  of  the  fork  are  completed.  If 
only  one  of  the  oblique  lines  is  complete,  the  partially  detached 
piece  of  bone  remains  attached  to  the  end  of  the  bone  on  the 
side  of  the  incomplete  oblique  line.  If  the  branches  of  the  fork 
are  complete,  the  base  of  the  triangular  fragment  is  directed 
toward  the  concavity  of  the  bend  created  by  the  fracturing  forces 
the  moment  the  accident  occurred.  In  complete  and  incomplete 
transverse  fractures  the  same  tendency  to  forking  of  the  line  of 
fracture  is  seen  in  the  form  of  fissures.      Messerer  has  shown  that 


Fig.  196. — Bending 
fracture  of  the  femur, 
with  detachment  of  a 
wedge-shaped  fragment 
on  the  convex  side  (after 
Bruns). 


Fig.  197. — Oblique 
fracture  of  the  shaft  of 
the  femur,  showing  an 
oblique  fissure  on  the 
lower  fi-agment  ( after 
Bruns). 


In 
re- 
of 


EXTERNAL    VIOLENCE.  329 

in  oblique  fractures  the  oblique  line  of  fracture  is  completed  only 
on  one  side  of  the  triangular  piece  of  bone,  the  other  side  being  in- 
dicated by  a  fissure.  Fractures  are  produced  either  by  direct  or  in- 
direct force,  in  the  former  case  the  fracture  occurring  at  the  point 
where  the  violence  is  applied  ;  in  the  latter,  the  fracturing  force  is 
transmitted  through  some  medium  to  the  seat  of  injury.  Fractures 
caused  by  a  fall,  a  blow,  a  kick,  or  by  projectiles  of  all  kinds  are 
good  illustrations  of  what  is  meant  by  fractures  resulting  from 
direct  force  if  the  fracture  takes  place  at  the  point  of  impact. 
Fractures  caused  by  direct  violence  are  always  attended  by  more 
injury  to  the  soft  tissues  than  fractures  resulting  from  indirect  force, 
and  are  more  frequently  compound,  as  the  same  force  that  causes 
the  fracture  commonly  destroys,  over  a  greater  or  less  extent,  the 
soft  tissues  between  the  point  of  impact  and  the  seat  of  the  fracture. 
Owing  to  the  existence  of  greater  injury  of  the  soft  parts  and  the 
greater  liability  to  the  recurrence  of  later  complications  in  fractures 
from  direct  than  indirect  force,  the  prognosis  is  graver  and  the 
treatment  more  difficult  in  the  former  than  in  the  latter  class,  so 
that  the  etiology  of  the  fracture  has  an  important  bearing  both  on 
the  prognosis  and  treatment.  Comminution  of  the  bone  is  more 
frequently  caused  by  direct  than  by  indirect  force. 

Indirect  fractures  occur  some  distance  from  where  the  force 
was  applied,  in  which  case  the  force  is  transmitted  through  the 
intact  bone  to  where  the  fracture  takes  place.  Fractures  of  the 
long  bones  by  indirect  force  are  caused  usually  by  a  fall  upon  the 
hands  or  feet  or  upon  the  elbows  or  knees.  In  fractures  of  the  neck 
of  the  femur  by  a  fall  upon  the  greater  trochanter  the  force  is  trans- 
mitted from  this  part  of  the  bone  through  the  neck  of  the  femur,  to 
the  seat  of  fracture,  while  in  fracture  of  the  femur  caused  by  a  fall 
upon  the  foot  the  force  is  transmitted  through  all  the  bones,  from 
the  point  of  impact  to  the  seat  of  fracture,  in  which  event  the 
ankle-joint  and  knee-joint  are  immobilized  in  the  extended  position 
by  muscular  contraction  at  the  moment  the  fracture  is  produced. 
Much  uncertainty  remains  in  explaining  satisfactorily  the  point  of 
localization  of  the  injury,  as  the  same  force  may  result  in  a  fracture 
near  where  it  is  applied,  and  in  other  instances  it  is  transmitted  a 
great  distance  through  several  bones. 

The  mechanism  of  indirect  fractures  is  a  variable  one.  In 
most  instances  the  fracture  is  caused  by  pressure  from  both  ends 
of  the  bone,  the  shaft  of  which  is  then  bent  beyond  its  elastic 
capacity,  the  fracture  usually  taking  place  where  the  convexity  of 
the  curvature  is  greatest.  For  instance,  in  fracture  resulting  from 
a  fall,  one  point  of  pressure  is  made  by  the  weight  of  the  body  and 
the  force  of  the  fall,  and  the  other  by  the  resistance  it  meets,  the 
two  opposing  forces  resulting  in  the  bending  of  the  bone  and, 
finally,  the  fracture.  In  other  instances  the  fracture  is  induced  by 
one  end  of  the  bone  being  fixed,  tlie  other  being  carried  onward, 
at  which  time  the  bending  and  fracture  occur  in  front  of  the  fulcrum. 


330 


FRACTURES. 


the  fixed  portion  of  the  bone.  The  force  is  expended  in  a  vertical 
direction  to  the  long  axis  of  the  bone.  Fracture  of  the  internal 
malleolus  by  forcible  adduction  of  the  foot,  and  fracture  of  the 
external  malleolus  by  forcible  abduction,  are  the  injuries  typical  of 
this  mechanism  of  indirect  fracture.  Another  mechanism  of  indirect 
fracture  is  represented  by  fracture  of  the  neck  of  the  femur  by  the 
transmission  of  force  through  the  shaft  of  the  bone.  It  is  the  only 
fracture  produced  in  this  manner.  The  neck  of  the  femur  is  placed 
at  an  angle  with  the  shaft  of  the  bone,  and  the  fracture  is  caused 

by  the  force  in- 
creasing this  angle 
beyond  the  elas- 
tic capacity  of  the 
bone. 

A  compression 
fracture  of  a  long 
bone  is  caused  by 
indirect  force  ap- 
plied to  both  ends, 
without  bending  the 
bone.  Such  frac- 
tures are  usually 
seen  near  one  of 
the  epiphyseal  ex- 
tremities, and  the 
shaft  of  the  bone 
is  driven  into  the 
spongiosa  of  the 
articular  end,  the 
impaction  being 
caused  by  a  con- 
tinuation of  the 
same  forces  that 
produced  the  frac- 
ture. Pressure  frac- 
tures from  transmitted  force  also  occur  in  a  number  of  the  articu- 
lations. The  head  of  the  radius,  the  rim  of  the  acetabulum  and 
glenoid  cavity,  and  the  anterior  margin  of  the  internal  malleolus 
furnish  such  instances  ;  more  frequent  are  the  traction  fractures. 
Hyperflexion,  hyperextension,  and  forcible  lateral  flexion  not  infre- 
quently result  in  articular  fracture  caused  by  contraction  made  by 
the  ligaments  when  these  are  more  resistant  than  the  bone  to 
which  they  are  attached.  Fractures  of  the  margins  of  the  mal- 
leoli thus  produced  furnish  the  most  familiar  illustrations  ;  many 
of  the  fractures  of  the  vertebrae  are  produced  in  this  manner. 

Violent  twisting  of  the  long  bones  around  their  axes  may  finally 
cause  what  is  known  as  a  torsion  fracture.  Fractures  produced  in 
this  manner  are  very  rare,  but  Bruns  and  others  have  reported  cases 


Fig.  198. — Compression  fracture  of  the  scaphoid  by  a  fall 
upon  the  palm  of  the  extended  hand. 


MUSCULAR    CONTRACTION. 


331 


in  which  the  fracture  was  evidently  produced  exclusively  by  this 
mechanism.  The  fracture  occurs  at  a  point  where  the  transverse 
resistance  of  the  bone  is  weakest,  and  the  line  of  fracture  is  spiral. 

The  injury  of  the  soft  tissues  in  indirect 
fractures  is  caused  b\'  the  displacement  of  the 
fragments.  If  an  indirect  fracture  is  made 
compound,  the  wound  is  made  from  within 
outward  by  perforation  of  the  skin  by  one  or 
more  fragments  by  the  same  force  that  pro- 
duced the  fracture. 

Muscular  Contraction. — Fracture  of  a  nor- 
mal bone  from  muscular  contraction  is  very 
rare  as  compared  with  fracture  from  external 
violence.  Fracture  from  this  cause  does  not 
exceed  from  0.5  to  i  per  cent.  Violent  con- 
traction of  the  voluntary  muscles,  the  usual 
involuntary  muscular  contraction,  as,  for  in- 
stance, during  convulsions  and  epileptic  sei- 
zures, is  the  exceptional  cause  of  fractures 
independently  of  external  violence.  As  frac- 
tures thus  produced  must  be  considered  only 
those  cases  in  which  other  intrinsic  and  exter- 
nal causes  can  be  excluded  as  the  essential 
vulnerating  force.  In  this  group  belong  those 
fractures  of  bony  prominences  that  serve  as 
points  of  insertion  of  powerful  muscles,  such 

as  the  coronoid  process  of  the  ulna  and  inferior  maxilla,  the  cora- 
coid  process  of  the  scapula,  the  greater  tubercle  of  the  humerus,  the 
greater  trochanter  of  the  femur,  and  the  tubercle  of  the  os  calcis. 

To  the  fractures  caused  by  muscular  contraction  must  be  added 
certain  fractures  of  the  patella,  which  embrace  about  one-third  of 
the  whole  number  of  fractures  of  this  bone.  Frac- 
ture of  the  patella  from  this  cause  occurs  from 
violent  contraction  of  the  quadriceps  extensor 
fcmoris  muscle  in  persons  who  make  a  violent 
effort  to  retain  the  erect  position  when  threatened 
by  a  fall  ;  or  muscular  contraction  takes  place 
when  the  knee  is  flexed,  in  which  case  the  frac- 
ture occurs  in  consequence  of  bending  and  trac- 
tion. Of  the  long  bones,  the  humerus  is  most 
frequently  the  .seat  of  fracture  from  muscular 
contraction.  Of  85  cases  of  fracture  from  mus- 
cular contraction  collected  by  Gurlt,  the  humerus 
was  the  seat  of  the  fracture  57  times,  the  femur 
25  times,  the  bones  of  the  leg  8  times,  and  the  forearm  5  times. 
The  humerus  is  broken  usually  during  an  attempt  to  throw  a 
stone  or  a  ball,  or  by  a  blow  tiiat  fails  to  rcacii  its  mark.  The 
accident   oocurs  at   tiic    moment   powerful    nniscles   arrest  further 


199. — Torsion 
of    the    femur 


Fi{j.  200.  — 
Mechanism  of  frac- 
ture of  the  patella 
by  muscular  action 
(Treves  j. 


332  FRACTURES. 

movement  of  the  arm.  In  fractures  of  the  neck  of  the  femur 
caused  by  hfting  a  heavy  object,  muscular  contraction  is  an  im- 
portant, if  not  the  sole,  element  in  the  mechanism  of  the  fracture. 
The  bones  of  the  forearm  have  yielded  to  violent  pronation  and 
supination.  The  head  of  the  fibula  in  rare  cases  gives  way  to 
violent  contraction  of  the  biceps  cruris  muscle,  while  the  shafts 
of  the  tibia  and  fibula  have  yielded  to  the  combined  influence  of  the 
weight  of  the  body  and  muscular  contraction.  Ribs  have  been 
broken  during  severe  attacks  of  coughing,  and  the  cervical  vertebrae 
may  fracture  during  violent  extension  caused  solely  by  muscular 
contraction.  In  fractures  of  the  clavicle  from  muscular  contraction 
the  sternocleidomastoid,  pectoralis  major,  and  deltoid  are  the  muscles 
concerned  in  the  production  of  the  fracture. 

Symptoms  and  Diagnosis. — In  the  majority  of  cases  the  signs 
and  symptoms  that  attend  a  fracture  are  so  prominent  that  a  diag- 
nosis can  be  made  without  any  special  difficulties,  but  there  are  cases 
in  which  the  immediate  results  of  the  injury  are  so  obscure  and  ill 
defined  that  it  is  very  difficult,  and  sometimes  impossible,  to  detect 
the  fracture.  In  such  doubtful  cases  the  patient  should  be  given 
the  benefit  of  the  doubt,  by  subjecting  the  injured  part  to  treatment 
for  fracture  that,  if  later  results  should  exclude  the  existence  of  a 
fracture,  will  prove  beneficial  in  the  treatment  of  the  injury  of  the 
soft  tissues  which  in  the  beginning  gave  rise  to  symptoms  that 
suggested  a  fracture.  It  is  better  for  the  patient  and  for  the  repu- 
tation of  the  physician  that  such  a  mistake  should  be  made  than  to 
overlook  a  fracture  and  fail  to  carry  into  effect  the  necessary 
mechanical  treatment  until  the  nature  of  the  injury  is  discovered, 
when  it  may  be  too  late  to  correct  the  consequences  of  the  over- 
sight. While,  as  a  rule,  it  is  not  difficult  to  determine  by  the  signs 
and  symptoms  presented  the  existence  of  a  fracture,  it  is  not  so  easy 
to  ascertain  its  exact  anatomic  location  and  line  of  fracture.  This 
is  especially  true  of  fractures  in  close  proximity  to  any  of  the  large 
joints.  The  evil  consequences  that  may  follow  an  incorrect  diag- 
nosis and  inaction  are  well  shown  in  cases  of  unrecognized  impacted 
fractures  of  the  neck  of  the  femur.  If,  in  such  cases,  the  seat  of 
fracture  is  not  immobilized,  the  impaction  very  often  gives  way  in 
three  or  four  weeks,  at  a  time  when  the  osteoporosis  that  precedes 
callus  formation  is  sufficiently  advanced  to  loosen  the  impacted 
fragment,  separation  of  the  fragments  taking  place  from  trivial 
causes.  The  failure  to  immobilize  the  fractured  bone  by  an  external 
mechanical  support  of  some  kind  is  largely  responsible  for  the  sec- 
ondary displacement  and  the  almost  inevitable  resulting  nonunion. 

The  differential  diagnosis  between  dislocation  and  fracture  within 
or  near  joints  is  often  very  difficult,  and  frequently  can  only  be 
made  after  a  most  careful  and  painstaking  examination.  Inexcusable 
blunders  have  been  made  in  practice  by  mistaking  fractures  of  the 
neck  of  the  femur  and  of  the  anatomic  and  surgical  necks  of  the 
humerus  for  dislocations.     The  additional  injuries  to  the  soft  tissues 


SUBJECTIVE    SYMPTOMS.  333 

inflicted  by  violent  attempts  to  reduce  a  supposed  dislocation  greatly 
add  to  the  gravity  of  the  injury  and  create  new  conditions  that  de- 
tract still  more  from  the  functional  result,  which  is,  as  a  rule,  bad 
enough  even  in  cases  in  which  a  correct  diagnosis  is  made  and  the 
proper  treatment  employed.  The  diagnosis  of  intercondyloid  frac- 
tures and  traumatic  epiphyseolysis  calls  for  the  most  careful  and  sys- 
tematic consideration  of  all  the  signs  and  symptoms,  and  gentle  but 
scrutinizing  examination.  Gentleness  and  care  should  characterize 
eveiy  examination  for  fracture.  Rough  and  reckless  handling  of  the 
injured  limb  inflicts  additional  injuries  of  the  soft  tissues  and  often 
of  the  broken  bone,  and  the  information  gained  does  not  compensate 
for  the  additional  trauma.  TJie  practitioner  xvJio  undertakes  the 
treatme7it  of  a  fractured  limb  assumes  a  moral  and  legal  responsibilitv 
that  can  only  be  met  by  the  carefid  employmeiit  of  all  known  diag- 
nostic resources  in  establishing  the  existence,  location,  and  nature  of 
the  fracture,  the  presence  or  absence  of  serious  complications,  the 
adoption  of  a  treatment  based  on  correct  mechanical  principles,  and 
unremitting  attention  during  the  after-treatment,  for  the  purpose  of 
securing  the  best  obtainable  functional  residt  compatible  zvith  the  nature 
of  the  injujy.  In  doubtful  and  trying  cases  the  practitioner  should 
avail  himself  of  the  services  of  at  least  one  of  his  neighboring  col- 
leagues, as  four  eyes  can  often  see  more  than  two,  and  four  hands 
can  feel  what  two  might  fail  to  detect.  Professional  jealousy  and 
personal  interests  must  not  come  into  conflict  w^ith  the  welfare  of  the 
patient  or  the  reputation  of  the  attending  physician  in  such  cases. 
To  assist  willingly  and  to  assume  the  joint  responsibility  of  the  case, 
together  with  the  protection  of  the  reputation  of  the  attending  phy- 
sician, should  be  the  endeavor  of  the  consultant  who  has  the  interest 
of  the  patient  and  the  honor  and  dignity  of  his  profession  at  heart. 

The  symptoms  of  fracture  are  divided  into  subjective  and  objec- 
tive. The  objective  symptoms  are  more  fully  relied  upon  in  mak- 
ing a  diagnosis  than  the  subjectiv^e  symptoms. 

Subjective  Symptoms. — The  three  subjective  symptoms  that 
deserve  the  attention  of  the  physician  before  he  undertakes  the 
examination  are  :  (i)  Loss  or  disturbance  of  function  ;  (2)  pain  ;  (3) 
tenderness.  Complete  loss  of  function  of  a  fractured  limb  is  a  fre- 
quent but  by  no  means  a  constant  symptom.  In  fractures  of  the 
shaft  of  the  femur  or  humerus  without  impaction  complete  suppres- 
sion of  function  is  the  rule  ;  the  same  can  be  said  of  fractures  of 
both  bones  of  the  leg  and  forearm.  If  only  the  fibula  or  one  of  the 
bones  of  the  forearm  is  fractured,  the  patient  ma}'  be  able  to  walk 
or  pronate  and  supinate  the  forearm.  A  number  of  well-authenti- 
cated ca.ses  of  impacted  fracture  of  the  neck  of  the  femur  have  been 
recorded  in  which  the  patient  walked  for  some  distance  after  the 
occurrence  of  the  accident.  In  the  absence  of  well-marked  defor- 
mity loss  and  impairment  of  function  can  not  be  relied  upon  as 
conclusive  diagnostic  evidences  of  fracture,  as  the  same  may  occur 
in  consequence  of  injury  of  the  soft  tissues   from  contusion.      In 


334  FRACTURES. 

the  absence  of  injury  of  the  soft  structures  sufficient  in  severity  and 
extent  to  account  for  loss  or  impairment  of  function,  the  existence 
of  a  fracture  should  always  be  suspected  and  the  necessary  careful 
examination  to  determine  its  location  be  made. 

Pain  as  a  source  of  diagnostic  information  is  of  no  value  in  the 
case  of  children,  and  very  unreliable  in  the  adult.  Every  fracture 
is  a  cause  of  pain,  but  its  location  and  intensity  do  not  always  cor- 
respond with  the  location  and  extent  of  the  injury.  The  severity 
of  the  pain  depends  more  upon  the  complicating  injuries  of  the  soft 
tissues  than  upon  the  fracture  itself  A  simple  fracture  with  little 
or  no  displacement  is  a  comparatively  painless  injury,  while  a  frac- 
ture with  much  displacement  is  usually  attended  by  severe  pain 
caused  by  the  irritation  of  the  soft  tissues  by  the  displaced  frag- 
ments. Aggravation  of  the  pain  by  passive  motion  would  indicate 
rather  a  fracture  than  a  contusion,  while  active  motion  might  in- 
crease the  pain  due  to  contusion  as  well  as  to  a  fracture. 

Tenderness  is  a  more  reliable  indication  of  the  existence  of  a 
fracture  than  spontaneous  pain.  Tenderness  as  a  symptom  of  frac- 
ture is  of  special  value  in  the  diagnosis  of  fractures  without  much 
displacement,  caused  by  indirect  force.  In  the  absence  of  deformity 
it  is  of  little  service  in  distinguishing  between  a  contusion  and  a 
fracture  the  result  of  direct  force,  as  in  both  instances  the  pain  would 
be  increased  under  pressure.  In  fractures  from  indirect  violence  a 
fixed  point  of  tenderness  on  pressure  and  movements  of  the  limb, 
by  either  active  or  passive  motion  and  continued  for  any  length  of 
time,  is  a  strong  presumptive  proof  of  a  fracture.  Fractures  of  the 
clavicle  with  little  or  no  displacement  and  greenstick  fractures  in 
children  can  often  be  located  by  this  symptom  alone.  A  circum- 
scribed fixed  point  of  tenderness  at  a  distance  from  where  the  injur- 
ing force  was  applied  must  therefore  be  looked  upon  as  proof  of  the 
probable  existence  of  a  fracture.  If  such  a  circumscribed  point  of 
tenderness  is  at  the  same  time  the  seat  of  an  ecchymosis,  the  sus- 
picion of  the  presence  of  a  fracture  is  converted  almost  into  a  cer- 
tainty. Fractures  of  the  clavicle  in  children  and  fractures  of  the 
fibula,  ribs,  and  lower  end  of  the  radius  in  adults  are  often  detected 
by  relying  largely  on  circumscribed  tenderness  as  the  immediate, 
and  ecchymosis  as  the  more  remote,  consequence  of  the  injury. 

Objective  Symptoms. — The  final  diagnosis  of  a  fracture,  con- 
cerning not  only  its  existence,  but  also  its  exact  location,  extent, 
and  nature,  and  the  search  for  serious  complications  are  based  on  a 
careful  study  of  objective  symptoms.  The  surgeon  who  takes  the 
time  and  pains  to  elucidate  the  objective  symptoms  singly  and  col- 
lectively is  the  one  who  will  be  least  likely  to  be  misled  in  diagnosis 
and  who  will  commit  the  fewest  errors  in  predicting  the  probable 
result.  Moreover,  he  it  is  who  will  obtain  the  best  functional  results 
as  the  highest  reward  for  timely  and  well-conducted  treatment, 
which,  under  his  personal  supervision,  is  continued  so  long  as  his 
services  are  required. 


OBJECTIVE    SYMPTOMS. 


335 


Before  the  objective  symptoms  are  searched  for  and  studied  it  is 
well  to  inquire  into  the  history  of  the  case  concerning  a  possible 
predisposition  to  fracture,  the  manner  in  which  the  injury  was  sus- 
tained, the  occurrence  of  a  pre\ious  fracture  under  exceptional  cir- 
cumstances, the  age  of  the  patient,  and  the  condition  of  the  bones. 
An  inherited  or  acquired  predisposition  to  fracture  will  help  to 
explain  the  existence  of  a  fracture  under  circumstances  that  would 
ordinarily  exclude  such  an  accident.  The  very  fact  that  the  patient 
had  sustained  fractures  before,  perhaps  from  trivial  causes,  would 
speak  in  favor  of  such  a  predisposition.  The  extremes  of  life  are 
predisposed  to  fractures,  dislocations  be- 
ing comparatively  rare.  Traumatic  epiph- 
yseoh'sis  is  an  injur}'  that  only  occurs 
in  individuals  before  the  age  of  puberty. 
The  existence  of  osteoporosis  and  soften- 
ing of  the  bones  in  any  part  of  the  skele- 
ton would  indicate  that  a  fracture  might 
occur  from  causes  that,  under  ordinary 
conditions,  would  exclude  such  an  acci- 
dent. 

The  objective  symptoms,  when  prop- 
erly considered,  are  the  guide-posts  that 
lead  to  a  correct  diagnosis.  Among 
these,  deformity  is  the  most  important. 
Deformity  as  the  result  of  a  fracture  is 
due  to  a  continuation  of  action  of  the 
force  that  produced  the  fracture,  muscu- 
lar contraction,  and  the  force  of  gravi- 
tation. In  impacted  fractures  of  the 
neck  of  the  femur  the  slight  degree  of 
shortening  and  outward  rotation  of  the 
limb  are  caused  by  the  crushing  of  bone 
under  the  same  traumatic  influence  that 
produced  the  fracture.  In  fracture  of 
the  neck  of  the  femur  without  impaction, 
the  shortening  of  the  limb  and  outward 
rotation  result  in  consequence  of  mus- 
cular contraction  and  the  weight  of  the 
limb. 

In  oblifjue  fractures  of  any  of  tlie  long  bones  the  shortening 
is  caused  almost  exclusively  by  muscular  contraction.  Angular 
deformity,  which  appears  immediately  after  the  injury,  must  be  con- 
sidered as  one  of  the  immediate  consequences  of  the  fracturing 
force.  The  appearance  of  this  deformity  more  remotely  from  the 
time  of  injury  is  conclusive  proof  that  the  deformity  was  caused  by 
the  force  of  gravitation,  or,  what  is  oftener  the  ca.se,  by  muscular 
contraction. 

The  displacements  of  the  fragments  arc  studied  by  making  use 


Fig.  20I.  —  Unimpacted 
fracture  of  neck  of  the  femur, 
with  marked  outward  rotation 
and  shortening  of  the  limb  (after 
IJruns). 


336 


FRACTURES. 


of  inspection,  measurements,  comparison  with  the  same  part  of  the 
body  on  the  opposite  side,  and,  in  exceptional  cases,  by  akidopei- 
rasty.  The  visible  and  palpable  deformity  that  attends  many  of  the 
fractures  is  often  the  most  striking  and  conclusive  proof  of  the 
existence  of  the  accident.  In  making  use  of  inspection  as  a  diag- 
nostic resource  it  is  important  to  expose  the  same  parts  of  the 
body  for  examination,  in  order  to  judge  correctly  the  deviations 
from  normal.  A  lack  of  caution  in  this  respect  has  not  infrequently 
resulted  in  erroneous  conclusions.  If  the  deformity  is  slight,  a 
most  careful  examination  is  necessary  to  detect  slight  deviations, 
which  is  only  possible  by  comparing  the  normal  side  or  limb  with 
the  injured.  An  abnormal  swelling  at  the  seat  of  injury  signifies 
displacement  of  the  fragments  or  an  extravasation  of  blood  if  it 
appears  immediately  or  soon  after  the  injury  occurred.  If  this 
swelling  increases  rapidly  in  size,  it  indicates  hemorrhage  at  the  seat 
of  injury  ;  if  more  slowly,  it  would  suggest  progressive  increase  of 
the  displacement  of  the  fragments  by  muscular  contraction,  or  slow 
hemorrhage  and  muscular  contraction  combined.  The  swelling  ap- 
pearing at  once 
or  soon  after  the 
injury  some  dis- 
tance from  where 
the  force  was  ap- 
plied, is  almost  a 
positive  indica- 
tion of  the  exis- 
tence of  a  fracture 
or  dislocation. 
The  presence  of 
a  sharp  fragment 
near  the  skin 
leaves  no  doubt  as  to  the  existence  of  an  oblique  fracture  caused 
by  direct  or  indirect  violence.  In  some  cases  such  a  fragment 
which  has  perforated  the  tissues  as  far  as  the  skin  forms  a  charac- 
teristic swelling,  in  the  apex  of  which  the  point  of  the  fragment 
can  be  distinctly  felt  as  a  sharp  subcutaneous  projection.  The 
appearance  of  suggillation  of  the  skin  some  days  after  the  occur- 
rence of  the  accident,  at  a  point  distant  from  where  the  force 
was  applied,  is  an  important,  but  not  a  reliable,  indication  of  the 
existence  of  a  fracture  or  dislocation.  In  compound  fractures 
the  fragments  can  often  be  seen  and  felt  in  the  wound.  In 
such  cases  inspection  and  digital  palpation  enable  us  to  make  an 
absolute  diagnosis  that  embraces  both  the  presence  and  extent  of 
the  fracture.  A  wound  of  the  soft  parts  is  not  an  infallible  proof 
either  of  the  existence  of  a  fracture  or,  in  the  event  of  a  fracture 
being  present,  of  its  being  compound.  A  wound  of  the  soft  tissues 
at  the  seat  of  injury  may  give  rise  to  symptoms  simulating  some  of 
the  symptoms   of   fracture,  and  a  wound  may  be  caused   by  the 


Fig.  202. 


-Fracture  of  both  bones  of  the  forearm,  with  marked 
angular  deformity  (after  Bruns). 


LATERAL    DISPLACEMENT. 


337 


fracturing  force  over  the  seat  of  fracture  without  a  communication 
having  been  established  between  it  and  the  seat  of  fracture. 

The  displacement  of  the  fragments  in  fractures  of  the  long  bones 
depends  largely  on  the  location  of  the  fracture,  the  manner  in  which 
the  injury  was  sustained,  muscular  contraction,  and  the  action  of 
various  extraneous  mechanical  forces  after  the  accident  occurred. 
The  deformities  that  immediatel}'  follow  the  accident  are  caused  by 
the  same  mechanical  force  that  produced  the  fracture  and  that,  by 
its  continued  action,  brought  about  displacement  of  the  fragments. 
More  remote  deformities  are 
usually  caused  b}-  muscular 
contraction,  loosening  of 
impacted  fractures,  gravita- 
tion, and  the  action  of  sub- 
sequent outside  mechanical 
causes.  The  displacements 
of  the  fragments  for  which 
the  surgeon  looks  and  upon 
which  lie  relies  largely  in 
ascertaining  the  existence 
and  location  of  a  fracture  of 
any  of  the  long  bones  are 
lateral,  angular,  rotary, 
overriding,  impaction,  and 
longitudinal. 

Lateral  Displacement. 
— Lateral  displacement  (dis- 
locatio  ad  latus)  as  an  iso- 
lated result  of  fracture  is 
ver)'  difficult  to  recognize 
by  inspection  and  palpation, 
except  in  case  the  broken 
bone  is  near  the  surface  of 
the  skin,  when  the  promi- 
nence of  the  displaced  frag- 
ment can  be  felt  and  seen. 
Lateral  displacement  in 
deep-seated  fractures  can 
not  be  determined  with  any 
degree  of  safety.     Fractures 

of  the  clavicle,  sternum,  tibia,  and  lower  end  of  the  radius  can  be 
detected  by  palj)ating  the  most  su[)crficial  parts  of  the  bones.  More 
frcc]ucntly  lateral  displacement  occurs  in  connection  with  angular 
dcformit}',  in  which  event  the  existence  and  extent  of  the  lateral 
dislocation  can  be  determined  with  a  greater  degree  of  accuracy. 

Angular  dislocation  of  the  fragments  (dislocatio  ad  axem)  is 
recognized  by  inspection  and  confirmed  by  i)al[)ation.  It  presents 
itself  clinicall)'  in  tiic  most  typical  manner  in  fractures  of  the  shafts 

22 


Fig.  203. — Transverse  fracture  of  upper 
part  of  the  radius,  with  marked  lateral  displace- 
ment. 


338 


FRACTURES. 


of  the  long  bones,  where  it  is  often  recognized  at  first  sight  on  ex- 
posure of  the  injured  limb.      In  fractures  of  the  femur  and  humerus 

it  is  almost  always 
associated  with  over- 
riding and  shortening 
of  the  limb,  while  in 
fractures  of  only  one 
bone  of  the  leg  and 
forearm  it  is  often 
seen  as  an  isolated 
deformity.  In  incom- 
plete fracture  by  in- 
fraction it  exists  as 
the  only  deformity, 
caused,  in  the  first 
place,  by  the  fractur- 
ing force,  increased 
later  by  muscular 
contraction. 


Fig.  204. — Deformity  at  the  wrist  consequent  upon 
displacement  backward  of  the  lower  fragment  of  the 
radius  after  fracture  at  its  lower  extremity  (Levis). 


Rotary  displacement  (dislocatio  ad  peripheriam)  is  recognized 
without   any  difficulty  by  comparing   the   two   limbs   and   noting 


Fig.  205. — Fracture  of  the  shaft 
of  the  tibia  and  of  the  fibula,  with 
external  rotary  displacement  (Hoffa). 


Fig.  206. — Impacted  fracture  of  the 
humerus  through  the  tuberosities  (R.  W. 
Smith). 


the   position  of  the   part   of  the   limb  below  the  fracture.       This 
displacement   is  seen    most    frequently   in   fractures  of  the   lower 


LONGITUDINAL    DISPLACEMENT. 


339 


extremity,  more  especialU'  in  fractures  of  the  neck  of  the  femur  with 
and  without  impaction,  when  outward  rotation  presents  itself  as  an 
almost  constant  phenomenon,  the  degree  of  eversion  being  deter- 
mined by  the  depth  of  the  impaction  and  the  extent  of  injury  to 
the  capsule  of  the  joint. 

Overriding  of  the  fragments  in  fractures  of  the  long  bones  is 
always  associated  with  angular  displacement.  It  is  seen  in  the 
most  typical  form  in  fractures  of  the  femur  and  clavicle  (Fig.  207). 

Impaction  gives  rise  to  abnormality  of  position  of  the  limb 
below  the  seat  of  fracture,  and  results  in  rotary  and  angular  de- 
formity in  proportion  to  the 
depth  of  the  impaction. 
Impaction  always  consti- 
tutes one  of  the  results  of 
the  fracturing  force.  One 
fragment  penetrates  the 
other  at  the  expense  of 
the  spongiosa,  which  is 
crushed  and  condensed  by 
the  penetrating  fragment. 
It  occurs  generally  in  the 
epiphyseal  extremities  of 
the  neck  of  the  femur  and 
the  neck  of  other  long 
bones,  notably  the  humerus 
and  lower  end  of  radius. 

Longitudinal  displace°° 
ment  (dislocatio  ad  longi- 
tudinem  cum  retractione)  is 
always  associated  with 
shortening  of  the  limb.  It 
can  only  take  place  when 
the  fractured  surfaces  no 
longer  furnish  a  mutual 
support — that  is,  when  in 
oblique  fractures  there  is  no 
support  between  the  frac- 
tured ends,  and  in  trans- 
verse fractures  when  the  lateral  displacement  is  complete.  Longi- 
tudinal displacement  occurs  in  consequence  of  muscular  contrac- 
tion, which,  if  not  antagonized  by  appropriate  mechanical  treat- 
ment, is  apt  to  increase  the  extent  of  the  shortening  gradually. 
If  the  shortening  is  marked,  it  is  recognized  without  difficulty  by 
inspection  ;  if  slight,  its  existence  must  be  determined  by  measure- 
ments. 

Measurements. — Mensuration  is  an  important  aid  in  the  detec- 
tion of  impacted  fractures  and  fractures  in  which  longitudinal  dis- 
placement has  occurred,  as  well  as  in  making  a  differential  diagnosis 


Fig.  207. — Fracture  of  lower  end  of  the 
shaft  of  the  femur,  with  overriding  of  the  frag- 
ments and  angular  deformity  (Hoffa). 


340 


FRACTURES. 


between  dislocation  and  fracture.  To  avoid  errors,  the  limbs  must 
be  placed  in  the  extended  normal  position  and  the  measurements  be 
made  on  both  sides,  between  the  same  anatomic  landmarks  that  are 

always  subcutaneous 
bony  prominences.  This 
diagnostic  resource  is  of 
special  value,  and  is  most 
frequently  employed  in 
fractures  of  the  femur 
and  humerus  and  injur- 
ies and  dislocations  of 
the  hip-  and  elbow- 
joints. 

In  making  compara- 
tive measurements  of  the 
lower  extremity  the  pa- 
tient must  be  placed  on 
his  back  upon  an  even, 
solid  surface,  the  pelvis 
and  limbs  exposed,  and 
thighs  and  legs  ex- 
tended and  parallel  to 
each  other.  In  sus- 
pected fracture  of  the 
femur  and  injuries  of 
the  hip-joint  the  fixed 
points  selected  are  the 
anterior  superior  spinous 
process  of  the  ilium  and 
the  lower  margin  of  the 
internal  malleolus.  If 
an  asymmetry  of  the  femur  is  suspected,  the  upper  margin  of  the 
head  of  the  fibula  or  the  middle  of  the  patella  is  taken  for  the 
lower  point  in  making  the  second  measurement.  In  injuries  of  the 
shoulder-joint   and   suspected   fracture  of  the   humerus  the  most 


Fig.  208. — Fracture  of  upper  and  lower  ends  of 
the  shaft  of  the  humerus,  with  marked  longitudinal 
displacement  (Hoffa). 


Fig.  209. — Tape-measures  :  A,  Linen  ;  B, 


prominent  point  of  the  acromion  process  and  the  head  of  the  radius 
or  one  of  the  epicondyles  of  the  humerus  is  the  prominence  selected 
for  the  measurements. 


PRETERNATURAL    MOBILITY.  34 1 

The  best  instrument  is  a  steel  tape-measure,  but  a  strong  thread 
or  a  tliin  wire  will  answer  an  excellent  purpose  in  showing  the  exis- 
tence, if  not  the  exact  amount,  of  shortening. 

In  measuring  the  upper  extremities  the  patient  should  be  in  a 
sitting  or  standing  position,  with  the  arms  resting  against  the  sides 
of  the  chest  and  the  forearms  either  extended  or  flexed  at  a  right 
angle. 

Comparison  between  the  injured  limb  or  part  with  that  of  the 
opposite  side  is  necessary  in  securing  accurate  results  from  exami- 
nation b\'  inspection,  palpation,  and  comparative  measurements. 
The  limbs  or  parts  must  be  placed  exactly  in  the  same  position, 
and  during  the  examination  the  alterations  that  take  place  during 
changes  of  position  are  noted. 

Akidopeirasty  of  Middeldorpf  consists  in  making  exploratory 
punctures  with  a  steel  needle  to  detect  abnormalities  of  resistance 
of  the  tissues  explored.  It  is  acupuncture  employed  for  diagnostic 
purposes,  and  it  is  occasionally  resorted  to  in  examination  for  frac- 
ture, in  order  to  demonstrate  lateral  displacement,  depression,  and 
the  presence  of  fissures.  The  needle  must  be  made  sterile  by  boil- 
ing in  soda  solution,  and  the  puncture  must  be  made  under  strictest 
aseptic  precautions.  Through  the  same  skin  puncture  the  tissues 
can  be  explored  in  different  directions. 

Preternatural  mobility  is  one  of  the  strongest  proofs  of  the  ex- 
istence of  a  fracture  of  any  of  the  long  bones.  This  s}'mptom  is 
absent  in  impacted  fractures.  If  abnormal  motion  can  be  detected 
immediately  after  an  injury  involving  the  continuity  of  a  long  bone, 
it  can  be  relied  upon  in  establishing  the  existence  of  a  fracture.  Im- 
portant as  this  symptom  is  in  making  a  diagnosis  of  fracture,  it  is  not 
always  present,  hence  absence  of  preternatural  mobility  would  not 
exclude  the  presence  of  a  fracture.  As  has  just  been  stated,  it  is 
absent  when  the  fragments  have  become  impacted,  and  it  is  slight 
in  greenstick  fractures  and  when  interlocking  of  the  fragments  has 
occurred,  and,  of  course,  is  always  absent  when  the  fracture  is  in- 
comjilete.  This  symptom  is  most  marked  in  fractures  of  the  shaft 
of  the  humerus  and  femur  and  in  fractures  of  both  bones  of  the  leg 
and  forearm.  In  fractures  of  the  fibula  and  of  either  the  radius  or 
ulna  alone  it  is  often  found  difficult  to  establish  the  existence  of  a 
fracture  by  relying  upon  this  symptom  alone.  In  obscure  cases  of 
fracture  in  the  nc{s^hborhood  of  Joints  preternatural  mobility  is  one  of 
the  most  reliable  symptoms  in  making  a  differential  diagnosis  between 
fractnre  and  dislocation,  as  it  ts  almost  witJiout  exception  present  in 
nonimpacted  fractures,  xvhile  impaired  mobility  is  one  of  the  constant 
features  of  all  dislocations.  Preternatural  mobility  and  altered  re- 
lations of  bony  landmarks  are  the  tu'o  conditions  that  unerringly  point 
to  afj'aetttre  near  or  extending  into  a  joint,  but  they  do  not  exclude 
the  presence  of  a  complicating  dislocation.  As  an  unmistakable  in- 
dication of  fracture  a  7icw  point  of  motion  is  of  greater  diagnostic  sig- 
nificance than  preternatural  motion.      The  latter  symi)tom  ai)plies 


342  FRACTURES. 

with  special  force  to  fractures  near  joints,  while  the  former  is  much 
relied  upon  in  the  search  for  fractures  of  the  shafts  of  the  long 
bones. 

A  new  point  of  motion  in  the  course  of  the  shaft  of  a  long  bone 
established  immediately  after  an  injury  leaves  no  further  doubt  con- 
cerning the  existence  of  a  fracture.  If  the  fracture  is  near  a  joint 
or  extends  into  it,  it  is  difficult,  if  not  impossible  in  many  cases,  to 
detect  the  new  point  of  motion,  and  the  injury  is  characterized  by 
preternatural  mobility  in  the  region  of  the  joint.  If  one  or  both 
of  the  condyles  of  the  femur  or  humerus,  or  any  of  the  subcutaneous 
prominences,  have  been  fractured,  a  new  point  of  motion  can  often  be 
ascertained  and  located  by  grasping  and  moving  the  fragment.  The 
search  for  a  new  point  of  motion  must  be  made  with  care,  as  the  ex- 
amination should  not  result  in  additional  injuries  to  the  soft  tissues 
or  greater  separation  of  the  fragments.  The  bone  or  bones  on  the 
proximal  side  of  the  supposed  seat  of  fracture  are  held  firmly  in  the 
grasp  of  one  hand,  while  with  the  other  the  limb  is  grasped  below  and 
moved  gently  in  a  lateral  direction,  when,  if  an  angle  forms  between 
the  fixed  and  the  moving  points,  the  necessary  information  has  been 
secured  and  the  existence  of  a  fracture  is  established.  Should  the 
first  effort  fail,  the  position  of  the  hands  is  changed  as  often  as  is 
necessary  to  test  the  continuity  of  the  entire  shaft.  If  the  suspected 
fracture  is  near  the  head  of  one  of  the  large  bones,  the  new  point 
of  motion  often  can  be  found  by  fixing  the  head  of  the  bone 
immovably  with  the  left  hand  and  by  rotating  the  shaft  with  the 
right. 

Crepitation  has  been  regarded  for  a  long  time  as  one  of  three 
pathognomonic  symptoms  of  fracture,  the  other  two  being  abnormal 
mobility  and  deformity.  As  an  indication  of  fracture  it  has  been 
greatly  overestimated  in  the  past,  and  too  great  reliance  upon  it  as 
a  diagnostic  resource  has  resulted  in  serious  injury. 

Crepitus  is  produced  by  rubbing  two  fractured  surfaces  together, 
when  the  mechanical  effect  produced  by  the  friction  between  the 
two  rough  surfaces  can  often  be  heard  as  well  as  felt.  The  produc- 
tion of  this  sign  of  fracture  by  the  surgeon  is  only  possible  when 
the  fracture  is  complete,  when  impaction  is  absent,  and  when  the 
two  fractured  surfaces  can  be  brought  in  contact  and  can  be  rubbed 
against  each  other  sufficiently  to  produce  the  necessary  mechanical 
effect  upon  Avhich  the  production  of  this  sign  depends — that  is,  a 
certain  degree  of  mobility  of  the  fragment  with  which  the  crepita- 
tion is  produced.  This  sign  is  necessarily  absent  in  incomplete  and 
impacted  fractures,  and  when  the  fragments  are  firmly  interlocked 
or  when  they  can  not  be  brought  in  contact,  owing  to  great  longi- 
tudinal displacement  or  interposition  of  soft  tissues.  Crepitation  is 
most  distinct  in  fractures  of  the  shaft  of  the  long  bones,  with  great 
mobility  of  the  fragments.  It  is  in  such  cases  that  patients  them- 
selves often  are  annoyed  by  the  sense  of  crepitation  on  the  slightest 
disturbance  of  the  limb,  even  after  the  fracture  has  been  properly 


THE    RONTGEX    RAY    IN    THE    DIAGNOSIS    OF    FRACTURES.         343 

dressed  and  immobilized.  If  other  symptoms  are  insufficient  to 
prove  the  existence  of  a  fracture,  it  is  justifiable,  by  the  gentlest 
means,  to  search  for  crepitus  as  an  indication  that  the  fragments 
have  been  brought  in  contact,  thus  excluding  the  presence  of 
interposition  of  soft  tissues  between  the  fragments — a  frequent 
mechanical  barrier  to  union  of  the  fracture  by  bony  callus. 

Crepitation  is  more  frequently  felt  than  heard,  and  the  vibra- 
tions are  often  conducted  a  considerable  distance  to  the  hand  with 
which  one  of  the  fragments  is  moved.  If  the  fragments  override 
each  other,  extension  must  first  be  made  sufficiently  to  bring  the 
fractured  surfaces  in  contact,  when  crepitus  is  produced  by  mak- 
ing careful  lateral  or  rotary  movements.  In  fracture  of  the  patella 
and  olecranon  process,  the  diastasis  must  be  eliminated  by  relaxing 
the  muscles  that  have  caused  the  injury,  when  the  fractured  sur- 
faces are  brought  in  contact  and,  by  rubbing  them  together,  crep- 
itus is  elicited,  provided  interposition  of  soft  tissues  does  not  prevent 
it.  In  fractures  of  the  ribs  crepitus  is  sometimes  produced  by  the 
respirator}^  movements  of  the  chest,  and  can  be  heard  by  placing 
the  stethoscope  over  the  seat  of  fracture,  as  was  first  suggested  by 
Lisfranc.  TJie  search  for  crepitation  should  never  he  made  unneces- 
sarily, as  in  viany  insta7ices  this  sign  is  absent,  and  in  the  vast  major- 
ity of  cases  a  satisfactory  diagnosis  can  be  made  by  a  careful  study 
and  analysis  of  the  other  symptoms. 

The  vibrations  produced  by  rubbing  torn  ligaments  together 
have  not  infrequently  been  mistaken  for  fracture  crepitus,  and  vice 
versa.  Cartilage  injuries,  disease  of  tendon  sheaths,  subcutaneous 
emphysema,  and  blood  extravasations  are  other  conditions  that  have 
given  rise  to  confusion  and  erroneous  conclusions  in  searching  for 
crepitus  as  a  sign  of  fracture.  The  greatest  care  is  necessary  iji  frac- 
tures of  the  neck  of  the  femur  and  anatomic  neck  of  the  laimerus  in 
making  attempts  to  elicit  crepitus  in  the  examination  of  impacted  frac- 
tures. It  is  in  such  cases  that  search  for  crepitus  has  been  followed 
by  the  most  disastrous  results  by  loosoiing  the  impaction,  thus  convert- 
ing a  fracture  into  an  almost  unavoidable  pseudarthrosis,  that,  under 
ordinary  care,  would  have  united  by  bony  consolidation.  In  nonim- 
pacted  fractures  of  the  neck  of  the  femur  the  other  symptoms  are 
so  apparent  that  a  correct  diagnosis  can  be  made  without  searching 
for  crepitus,  and  in  impacted  fractures  the  production  of  this  sign 
implies  loosening  of  the  impaction,  a  positive  diagnosis  at  the  expense 
of  a  permanent  disability.  In  doubtful  cases  it  is  much  better  to 
take  it  for  granted  that  the  fracture  is  an  impacted  one,  and  treat  it 
as  such  for  the  necessar)'  length  of  time,  rather  than  insist  on  mak- 
ing a  positive  diagnosis,  with  the  risks  incident  to  such  an  attempt. 

The  Rontgen  Ray  in  the  Diagnosis  of  Fractures. — The  X-ray 
is  the  most  recent  acquisition  to  the  diagnf)stic  resources  of  frac- 
tures, and  in  obscure  cases  has  become  almost  indispensable.  It  is 
of  s[)ecial  value  in  determining  the  existence  and  location  of  frac- 
tures near  jfjints,  and  in  showing  the  presence  or  absence  of  com- 


344 


FRACTURES. 


plicating  dislocations.  It  will  also  be  found  of  the  utmost  value  in 
showing  the  position  of  the  fragments  and  the  causes  that  interfere 
with  their  reposition,  among  them  the  interposition  of  soft  tissues. 
The  fluoroscope  used  in  connection  with  the  Rontgen  apparatus 
will  aid  the  surgeon  in  determining  whether. or  not  his  efforts  at  re- 
duction have  been  successful.  If  his  efforts  have  failed,  it  may  point 
out  to  him  the  obstacles  which  are  in  the  way  and  which  must  be 
removed  before  the  fragments  can  be  brought  in  contact.  In  old 
fractures  united  in  malposition,  and  in  old  dislocations  unreduced, 
skiagraphy  has  become  a  very  useful  and  often  necessary  procedure 
preliminary  to  efforts  at  reduction,  as  it  will  reveal  the  precise  rela- 
tions of  the  fragments  in  a  vicious  union  and  the  exact  location  of 
the  dislocated  head  of  the  bone  and  its  relations  to  adjacent  im- 
portant structures.  The  information  thus  gained  will  be  of  material 
assistance  in  deciding  upon  the  propriety  of  active  interference  in 
correcting  the  deformity,  and  in  reducing  the  dislocation  by  either 
the  bloodless  or  the  open  method.  To  make  skiagraphy  reliable  as  a 
diagnostic  resource  it  is  often  necessary  to  make  the  illumination  in 
different  directions,  as  otherwise  it  may  lead  to  serious  deceptions. 

Symptoms  Following  Fractures. — The  more  remote  symp- 
toms of  fracture  may  either  clear  up  or  obscure  the  diagnosis. 

Shock,  more  or  less  marked,  is  present  in  nearly  every  case  of 
fracture.  Fractures  caused  by  direct  force  are,  as  a  rule,  attended 
by  greater  depression  than  fractures  from  indirect  violence,  owing  to 
the  existence  of  more  extensive  injury  to  the  soft  tissues,  upon  the 
extent  of  which  shock  largely  depends.  Pallor,  fainting,  a  feeble 
pulse,  later  nausea  and,  in  more  serious  cases,  real  shock,  are 
the  principal  general  nervous  manifestations  caused  by  fractures. 
Profound  shock  is  one  of  the  great  dangers  of  extensive  crushing 
injuries.  Simple  fractures  are  almost  constantly  followed  by  more 
or  less  shock. 

Fever. — Independently  of  infection,  the  febrile  reaction  which,  as 
a  rule,  sets  in  a  few  hours  after  the  accident  has  occurred  is  caused  by 
ferment  intoxication.  The  fibrin  ferment  is  a  product  of  coagula- 
tion necrosis  of  the  blood  extravasated,  and  when  a  sufficient  quan- 
tity finds  its  way  into  the  general  circulation,  a  rapid  rise  in  the 
temperature  and  other  febrile  phenomena  develop  in  rapid  succes- 
sion. Fermentation  fever  from  this,  as  well  as  from  any  other, 
cause  differs  clinically  from  fever  caused  by  microbic  infection  in 
that  the  fever  sets  in  within  a  few  hours  after  the  accident.  Although 
the  temperature  may  be  high,  the  pulse  rapid,  full,  and  bounding,  the 
subjective  symptoms  are  light ;  the  tongue  remains  moist,  vomit- 
ing and  diarrhea  are  absent,  there  are  no  chills,  appetite  remains 
unimpaired,  and  the  patients  are  seldom  willing  to  acknowledge 
that  they  are  ill.  The  fever  is  of  short  duration  and  disappears  as 
suddenly  as  it  came  on,  with  the  elimination  of  the  fibrin  ferment. 
The  anioimt  of  extravasated  blood  bears  no  relation  whatever  to  the 
intensity  and  duration  of  the  fever,  as  a  small  extravasation  may  give 


LOCAL    SYMPTOMS PAIN.  345 

rise  to  a  high  fever  that  may  continue  for  several  days,  and  a  large 
extravasation  may  exist  rvitJi  little  or  no  rise  in  the  temperature.  The 
conditions  that  determine  fermentation  fever  are  as  yet  not  well 
understood,  and  await  a  more  satisfactory  explanation  by  additional 
experimental  research  and  more  accurate  clinical  observations. 

Local  Symptoms. — With  the  general  and  local  reaction  the  seat 
of  fracture  is  very  liable  to  undergo  changes  that  give  rise  to  addi- 
tional symptoms.  In  simple  fractures  such  changes  do  not  occur, 
and  if  they  do,  only  to  a  slight  extent,  when  the  extravasation  of 
blood  is  limited,  when  the  fragments  are  in  accurate  contact  and 
perfectly  immobilized.  A  copious  blood  extravasation,  comminu- 
tion and  imperfect  reduction,  and  immobilization  are  responsible 
for  increase  of  the  swelling,  extensive  ecchymosis,  blistering  of  skin, 
and  a  continuation  of  pain.  In  the  absence  of  infection  a  gradual 
increase  in  the  size  of  the  swelling  indicates  a  continuation  of 
hemorrhage  at  the  seat  of  fracture  and  infiltration  of  the  loose 
connective  tissue  with  blood.  In  such  cases  the  swelling  becomes 
larger  and  more  extensive  soon  after  the  injur}-,  or,  if  the  swelling 
increases  in  size  later,  it  is  caused  by  an  obstructed  venous  circula- 
tion, and  its  direct  consequence,  edema.  Very  often  these  two 
pathologic  conditions  caused  by  the  trauma  are  associated,  when 
the  limb,  at  and  below  the  seat  of  fracture,  becomes  enormously 
swollen,  the  skin  very  tense,  and  blisters  form,  filled  with  a  yellow 
or  reddish  serum.  The  appearance  of  such  bullae  have  often  caused 
unnecessary  alarm,  not  only  on  the  part  of  the  patient,  but  also  to 
the  physician,  who  regarded  them  as  indications  of  the  approach  of 
gangrene.  These  blisters  indicate  impeded  venous,  and  an  embar- 
rassed capillary,  circulation,  but  if  the  principal  blood-vessels  have 
escaped  injury,  no  fear  of  gangrene  need  be  entertained.  The  con- 
tents of  these  blisters  should  be  removed  by  puncture,  the  cuticle 
carefully  preserved  and  protected  by  dusting  with  borosalicylic 
acid,  and  covered  with  hygroscopic  sterile  cotton. 

Ecchymosis  appears  early  and  is  most  extensive  if  the  blood 
extravasation  is  diffuse  and  near  the  surface  of  the  skin  ;  late,  and 
perhaps  at  quite  a  distance  from  the  seat  of  fracture,  if  the  extrava- 
sation is  underneath  a  firm  fascia  and  a  deep  layer  of  uninjured 
muscle.  In  fractures  caused  by  direct  violence  the  ecchymosis 
appears  early  over  the  seat  of  fracture,  and  may  be  caused  by  the 
contusion  of  the  soft  parts.  In  indirect  fractures  it  comes  on  later, 
over  the  seat  of  fracture  or  at  some  distance,  but  as  an  indication 
of  fracture  remote  from  where  the  fracturing  force  was  applied.  If 
the  ecchymosis  is  intense,  the  discoloration  is  at  first  black,  which, 
as  the  absorption  of  the  coloring  material  of  the  blood  progresses, 
fades  gradually  into  green,  deep  yellow,  light  yellow,  and  finally 
into  the  normal  color  of  the  skin. 

Pain. — The  continuation  of  pain  should  always  remind  the  sur- 
geon of  the  necessity  of  investigating  its  cau.sc.  Instead  of  admin- 
istering opiates,  it  becomes  the  duty  of  the  surgeon  to  seek  for  and 


346  FRACTURES. 

remove  its  cause.  Continuation  of  pain  after  the  fracture  has  been 
reduced  and  dressed  is  a  strong  indication  of  imperfect  work,  either 
in  effecting  complete  reduction  or  because  of  unequal  harmful  pres- 
sure on  the  part  of  the  splints  or  a  faulty  position  of  the  limb.  The 
splints  should  be  removed,  the  seat  of  fracture  examined,  the  neces- 
sary corrections  made  if  the  fragments  are  found  in  faulty  position, 
and  if  the  dressing  has  caused  the  pain,  the  defects  are  remedied 
and  the  limb  placed  in  the  most  comfortable  position. 

Serious  Complications  of  Simple  Fractures. — One  of  the  com- 
mon oversights  in  the  examinations  for  fracture  in  the  practice  of 
most  general  practitioners  is  a  failure  to  make  a  careful  investiga- 
tion concerning  the  presence  of  serious  complications  involving  the 
principal  blood-vessels  and  large  nerve-trunks.  Many  grave  conse- 
quences have  followed  simple  fractures  when  least  expected,  because 
at  the  first  examination  no  careful  investigation  was  made  regarding 
the  condition  of  the  principal  blood-vessels  and  nerves.  This  part 
of  the  examination  should  never  be  neglected  ;  it  is  superfluous  in 
the  majority  of  cases,  but  of  far-reaching  importance  in  isolated 
cases.  The  average  physician  is  usually  content  with  limiting  his 
diagnostic  work  to  the  bone  injury,  and  in  so  doing  serious  compli- 
cations are  occasionally  overlooked  that  are  of  the  utmost  prognostic 
importance.  The  main  artery  of  a  limb  is  occasionally  injured  by 
the  fracturing  force,  or  the  circulation  is  suspended  or  impaired  by 
compression  caused  by  displaced  fragments,  conditions  that  may 
result  in  gangrene,  an  occurrence  for  which  the  treatment  of  the  frac- 
ture is  more  frequently  blamed  than  the  injury.  Traction  injuries 
sometimes  rupture  the  intima  of  the  principal  artery,  an  accident 
which  at  once  diminishes  the  blood  supply  and  is  followed  in  a  short 
time  by  complete  obliteration  of  the  injured  blood-vessel  by  the 
formation  of  a  thrombus.  The  condition  of  the  peripheral  circula- 
tion should  always  be  carefully  noted,  not  only  in  making  the  first 
examination,  but  also  day  after  day  subsequently,  to  gain  timely 
knowledge  of  vascular  complications  that  might  threaten  the  life  of 
the  limb  and  of  the  patient. 

Rupture  of  large  nerve-trunks  by  the  fracturing  force  or  indi- 
rectly by  the  fragments  is  a  very  serious  complication,  and  one  that  is 
not  infrequently  overlooked.  Such  accidents  are  more  frequently 
detected  later  than  at  the  time  the  first  examination  is  made.  The 
physician  should  never  complete  his  examination  of  any  fracture 
until  he  has  ascertained  the  condition  of  the  nerves  below  the  seat 
of  injury.  This  he  does  by  testing  sensation  and  motion  in  the 
course  of  the  principal  nerve -trunks,  thus  better  preparing  him  to 
render  a  reliable  prognosis  and  to  protect  himself  against  unneces- 
sary and  undeserved  blame. 

Suppuration. — Infection  of  a  subcutaneous  fracture  is  an  ex- 
tremely rare  occurrence,  and  in  this  respect  the  results  of  experi- 
mentation appear  to  be  at  variance  with  clinical  experience.  A 
number  of  experimenters  have  succeeded  very  frequently  in  pro- 


FAT    EMBOLISM.  34/ 

ducing  an  osteomyelitis  at  the  seat  of  a  subcutaneous  fracture, 
artificially  produced,  by  injecting  into  the  general  circulation  pus- 
microbes  either  before  or  after  the  injury  was  inflicted.  The  rarity 
with  which  osteomyelitis  is  met  in  subcutaneous  fractures  as  an 
early  or  a  remote  complication  would  seem  to  prove  that  the  blood 
and  tissues  of  persons  apparently  in  good  health  do  not  contain 
enough  microbes  to  develop  a  suppurative  inflammation  at  the 
locus  mi)ioris  rcsistcnticB  created  by  the  fracture.  A  number  of 
well-authenticated  cases  of  complicating  osteomyelitis  have,  how- 
ever, been  reported,  and  I  recall  two  very  interesting  cases  that 
came  under  my  own  observation.  In  both  cases  the  subcutaneous 
fracture  became  infected  about  a  week  after  the  accident  occurred. 
Abscess  formation  and  limited  sequestration  followed  and  retarded 
the  process  of  repair,  but  eventually  the  fracture  united  in  a  satis- 
factory manner.  The  osteomyelitis  resembles,  in  its  beginning  and 
in  its  course,  acute  osteomyelitis  without  fracture,  with  this  excep- 
tion :  that  the  pain  during  the  early  stages  of  the  disease  is  less 
severe.  A  chill,  followed  by  a  rapid  rise  in  temperature,  pain, 
tenderness,  and  a  rapidly  forming  diffuse  swelling  at  the  seat  of 
fracture,  which  soon  presents  fluctuation,  are  the  most  important 
clinical  features  of  this  complication. 

The  inflammatory  process  differs  from  so-called  spontaneous 
osteomyelitis  in  several  respects,  owing  to  the  existence  of  the 
fracture.  The  pain  is  not  so  intense,  intra-osseous  tension  is 
diminished  by  the  fracture,  and  swelling  of  the  soft  tissues  comes 
on  at  an  earlier  period,  because  the  osteomyelitic  product  finds 
its  way  into  the  loose  connective  tissue  through  the  open  ends  of 
the  fragments.  Finally,  the  absence  of  intra-osseous  tension  and 
the  early  and  free  escape  of  the  product  of  the  suppurative  inflam- 
mation into  the  surrounding  soft  tissues  explain  satisfactorily  why, 
as  a  rule,  the  sequestration  is  limited.  Although  such  compli- 
cations are  very  rare  indeed,  they  must  be  looked  for  and  recog- 
nized as  soon  as  they  appear,  as  early  incision  and  free  drainage 
under  strict  a.septic  precautions  will  minimize  the  danger  from 
pyemia  and  greatly  limit  the  destruction  of  bone  and  soft  tissues, 
together  with  hastening  the  initiation  of  a  process  of  repair.  In- 
cision and  drainage  convert  the  subcutaneous  into  an  open  fracture, 
which  should  then  receive  the  same  surgical  and  mechanical  treat- 
ment as  infected  compound  fractures  receive. 

Fat  Embolism. — One  of  the  lea.st  dangerous  but  most  frequent 
complications  of  fractures  is  fat  embolism.  Fat  embolism  as  a  com- 
plication of  fracture  and  as  a  cause  of  sudden  death  was  first  de- 
scribed by  Zenker  in  1862.  It  has  since  been  made  the  subject  of 
careful  clinical  and  experimental  investigation,  and  numerous  cases 
have  been  recorded,  substantiated  by  carefully  made  postmortems. 

The  most  elaborate  description  of  fat  embolism  that  serves  as 
the  basis  of  all  writings  on  this  subject  we  owe  to  Wiener  and 
Scriba.     Fat  embolism  of  a  slight  degree  and  unattended  by  symp- 


348  FRACTURES. 

toms  is,  in  all  probability,  a  frequent  accompaniment  of  fractures, 
especially  in  fractures  involving  the  medullary  canal  of  the  shaft  of 
a  long  bone.  Comminution  of  the  bone  and  crushing  of  the  medul- 
lary tissue  favor  the  occurrence  of  fat  embolism,  and  are  prone  to 
give  rise  to  grave  forms  which  may  destroy  life  suddenly  or  in  a 
short  time. 

The  frequency  with  which  fat  embolism  occurs  in  fractures  is 
best  shown  by  the  experiments  made  by  Halm.  In  13  animals 
he  produced  bone  injuries  under  a  hydraulic  press,  varying  in  in- 
tensity from  a  simple  fracture  to  complete  crushing  of  the  bone,  and 
found  fat  embolism  of  the  lungs  and  other  organs  12  times.  The 
only  animal  in  which  it  was  not  found  was  the  one  in  which  a 
wedge-shaped  piece  was  removed  from  the  femur  without  injury  to 
the  medulla.  One  of  the  essential  conditions  in  the  etiology  of  fat 
embolism  is  the  presence  of  fluid  fat,  and  this  is  produced  in  frac- 
tures b}^  crushing  of  the  medullary  tissue,  which  liberates  free  fat 
globules.     Another  source  of  fluid  fat  is  the  fat  tissue  involved  in 

the  injury,  which,  when  crushed,  like- 
wise furnishes  free  fluid  fat.  A  few 
well-authenticated  cases  of  fat  embolism 
have  been  reported  in  which  there  was 
no  fracture,  but  extensive  contusion  of 
fat  tissue,  from  which  the  fluid  fat  was 
derived  exclusively. 

In  fractures  we  find  another  condi- 
tion that  predisposes  strongly  to  fat 
embolism — the  wide-open  lumina  of  the 
vessels  of  the  medullary  tissue.  The 
pressure  caused  by  the  displaced  frag- 
Fig.  210.— Fat  globules  and      ^ents  and  by  the  blood  extravasation, 

blood-corpuscles    in    capillaries  .  ,     ,    ,  .        .  ^     ,  .  . 

(after  Perls).  aided  by  aspiration  01  the  open  veins,  is 

the  principal  active  agent  in  forcing  the 
liberated  air  globules  into  the  venous  circulation.  The  torn  veins 
are  the  main  avenues  for  the  entrance  of  free  fat  into  the  circula- 
tion, although  it  has  been  shown  that  it  may  also  gain  access  indi- 
rectly through  the  lymphatic  channels.  In  the  latter  case,  however, 
the  oil  globules  are  emulsified  in  the  lymph-glands  to  an  extent 
which,  according  to  Riedel,  renders  them  harmless  in  the  general 
circulation.  The  entrance  of  fat  into  the  circulation  occurs  soon 
after  the  injury,  as  the  open  veins  are  speedily  blocked  by  coagu- 
lated blood.  The  oil  globules  that  find  their  way  into  the  venous 
circulation  are  arrested  chiefly  in  the  pulmonary  filter  of  capillary 
vessels.  In  the  capillary  vessels  the  oil  globules  become  attached 
to  the  intima,  coalesce,  and  form  larger  drops  which  finally  com- 
pletely fill  the  lumina  of  the  smallest  capillary  vessels.  In  the 
capillary  network  are  found,  between  the  emboli  of  fat,  capillary 
vessels  filled  with  blood.  The  smallest  part  of  the  fat  passes  the 
pulmonary  filter  and  reaches  the  various  distant  organs,  particularly 


FAT    EMBOLISM. 


349 


the  kidneys,  liver,  spleen,  brain,  spinal  cord,  and  the  digestive  tract, 
where  it  again  blocks  capillary  blood-vessels. 

The  embolic  fat  acts  as  an  aseptic  plug,  and  does  not  cause  in- 
flammation, sepsis,  and  pyemia,  as  was  formerly  asserted.  The 
danger  from  fat  embolism  arises  solely  from  the  mechanical  ob- 
struction of  blood-vessels,  and  the  degree  of  danger  is  proportionate 
to  the  extent  of  the  capillary  obstruction.  The  hemorrhagic  infarcts, 
which  are,  however,  not  constant  in  fat  embolism,  are  caused  by 
obstruction  of  capillaries  of  considerable  size,  around  which,  from 
smaller  engorged  capillaries,  rhexis  takes  place.  Paralysis  of  the 
heart  has  been  regarded  by  Bergmann  and  Panum  as  the  immediate 
cause  of  fat  embolism,  but  the  very  elaborate  researches  and  numer- 
ous experiments  of  Scriba  lead  to  an  opposite  conclusion.  He  has 
shown  that  ex- 
tensive fat  em- 
bolism has  no 
disturbing  influ- 
ence on  the  ac- 
tion of  the  heart. 
If  the  subjects 
of  fat  embolism 
escape  the  im- 
mediate and  re- 
mote conse- 
quences of  ob- 
struction of  the 
pulmonary  cap- 
illaries, the  em- 
boli are  de- 
tached in  the 
course  of  from 
eight  to  twelve 
days,  and  find 
their  way  into 
the  general  cir- 
culation.      This 

may  give  ri.se  to  embolism  in  distant  organs,  when,  in  the  course 
of  time,  the  fat  is  again  liberated  and  finds  its  way  back  into  the 
pulmonary  capillaries,  again  causing  embolism.  As  these  succes- 
sive liberations  and  new  embolic  processes  occur,  the  kidneys 
continue  to  eliminate  fat  periodically,  until  finally  all  the  fat  that 
has  not  already  been  absorbed  by  the  tissues  the  seat  of  the  differ- 
ent embolic  proces.ses  is  removed  by  this  route. 

The  a[)pearance  of  fat  in  the  urine  after  injuries  is  an  indication  of 
the  exi.stence  of  fat  embolism.  Riedcl  found  fat  in  the  urine  in  all  cases 
of  fracture.  Halm  found  it  present  in  28  per  cent.,  and  Riedel  in  42 
per  cent.,  of  the  cases.  It  is  only  in  the  graver  cases  of  fat  embol- 
ism that  free  fat-drops  appear  on  the  surface  of  the  urine.      In  most 


Fig.  211. — Fat  embolism  of  the  lungs,  eight  days  after  frac- 
ture of  the  leg.  The  capillary  network  to  the  right  of  the 
alveolus  is  filled  with  blood,  the  one  below  with  fat ;  also  the 
afferent  artery.  Above  the  artery  blocked  with  fat  are  seen 
two  air-bubbles  showing  several  dark  rings,  and  extravasant  oil 
globules  with  plain  black  contour  (after  Perls). 


350  FRACTURES. 

of  the  cases  the  fat  appears  in  the  form  of  a  cloudy,  mucoid  layer 
on  the  surface  of  urine  that  has  been  allowed  to  stand  for  some 
time.  Under  the  microscope  the  fat  is  seen  in  the  form  of  round, 
strongly  refracting  granules,  with  fine,  dark  contours,  never  ex- 
ceeding in  size  that  of  half  a  blood-corpuscle.  These  granules 
adhere  to  one  another  or  are  irregularly  distributed  over  the  field. 

These  small  drops  of  fat  never  coalesce.  Scriba  has  shown 
that  elimination  of  fat  through  the  kidneys  takes  place  periodically. 
The  first  appearance  of  fat  in  the  urine  occurs  from  the  second  to 
the  fourth  day  after  the  accident ;  the  second  in  from  ten  to  fourteen 
days,  and  so  on,  at  intervals  of  from  six  to  ten  days.  In  the 
experiments  on  animals  a  prompt  and  decided  reduction  in  the  tem- 
perature was  observed,  which  reached  its  lowest  level  in  from  six  to 
ten  hours.  In  the  fatal  cases  the  temperature  continued  to  sink 
until  death  ensued.  The  rise  in  temperature  so  constantly  observed 
after  fracture  has  been  attributed  by  Wagner,  Busch,  and  Berg- 
mann  to  mild  forms  of  fat  embolism.  Subsequent  observations, 
however,  and  more  particularly  the  results  of  experiments,  have 
shown  most  conclusively  that  fat  embolism  has,  if  any,  an  opposite 
effect,  and  when  the  temperature  is  increased,  the  febrile  distur- 
bance is  not  due  to  fat  in  the  circulation,  but  to  a  coexisting  ferment 
intoxication.  In  extensive  fat  embolism  of  the  pulmonary  capillaries 
difficulty  in  breathing  and  cyanosis  are  the  most  prominent  symp- 
toms, and  in  fatal  cases  death  from  asphyxia  may  occur  suddenly. 
If  the  patient  survives  the  first  invasion,  later  symptoms  of  a  similar 
but  less  severe  character  announce  a  repetition  of  the  same  process 
or  vascular  disturbances  caused  by  hemorrhagic  infarcts. 

A  severe  collapse  inaugurates  the  gravest  cases  of  fat  embolism, 
which  differs  from  traumatic  shock  in  that  it  does  not  make  its 
appearance  immediately ,  but  some  time  after  the  accident.  In  the 
fatal  cases  great  pallor  of  the  skin  and  mucus  membranes,  loss  of 
strength,  apathy,  diminished  sensibility,  and,  at  times,  convulsions 
and  paralysis  follow  in  succession,  the  paralysis  finally  involving 
the  respiratory  centers. 

Experiments  on  the  lower  animals  have  shown  that  the  danger 
from  the  presence  of  fat  does  not  depend  so  much  on  the  amount 
of  fat  introduced  as  it  does  on  the  force  with  which  it  is  introduced 
and  the  time  taken  in  injecting  it.  The  same  amount  of  fat  injected 
with  force  quickly  into  a  vein  near  the  heart,  with  the  result  of 
causing  immediate  death  of  the  animal,  when  injected  into  a  per- 
ipheral vein  slowly  will  cause  no  serious  or  remote  ill  results.  Bruns 
has  collected  no  fatal  cases  of  fat  embolism  that  have  been 
reported  in  literature,  but  he  very  properly  insists  that  in  many  of 
these  cases  death  was  the  result  of  other  complications. 

The  differential  diagnosis  between  acute  sepsis  and  fat  embolism 
is  sometimes  very  difficult,  if  not  impossible.  In  subcutaneous 
fractures  a  differential  diagnosis  between  these  two  complications  is 
seldom  made  necessary.     A  high  temperature  always  excludes  fat 


TRAUMATIC    EMPHYSEMA.  3  5  I 

embolism  as  the  sole  or  principal  source  of  danger,  and  should 
always  remind  the  surgeon  of  the  necessity  for  searching  for  other 
complications  that  are  responsible  for  the  febrile  disturbance.  Prac- 
tical experience  and  experiments  on  the  lower  animals  have  demon- 
strated the  frequenc)'  with  which  bone  injuries  give  rise  to  fat 
embolism,  but  they  have  likewise  shown  that  death  from  uncom- 
plicated fat  embolism  is  very  rare. 

The  only  rational  treatment  for  fat  embolism,  if  it  becomes  a 
source  of  danger  to  life,  is  the  administration  of  stimulants. 

Traumatic  Emphysema. — In  subcutaneous  fractures  traumatic 
emphysema  is  caused  by  the  entrance  of  air  into  the  loose  con- 
nective tissue  around  the  seat  of  fracture.  The  fracture  in  such 
cases  communicates  with  some  part  of  the  respiratory  passage,  and 
the  air  finds  its  wa}'  through  the  mucous  passage  by  means  of  a 
connecting  wound  in  the  mucous  lining,  to  the  seat  of  fracture. 
Fractures  of  this  kind  are  open  fractures,  but  differ  from  fractures 
that  communicate  with  a  wound  of  the  skin  in  that  they  are  not 
exposed  to  contact  infection,  as  the  air  which  enters  from  the 
bronchial  or  tracheal  wounds  is  filtered  air,  practically  sterile.  In 
traumatic  fractures  communicating  with  the  air-passages  the  air  is 
forced,  during  the  end  of  the  expiratory  act,  through  the  wound 
into  the  loose  connective  tissue,  producing  traumatic  emphysema. 
Fractures  of  the  ribs  that  penetrate  the  pleura  and  lungs  and  frac- 
tures of  the  larynx  and  trachea  are  most  frequently  the  seat  of 
traumatic  emphysema. 

Traumatic  emphysema  also  occurs  occasionally  in  connection 
with  fracture  of  the  bones  of  the  face  which  communicate  with  the 
cavity  of  the  mouth,  the  nasal  cavity,  the  antrum  of  Highmore,  and 
the  frontal  sinus.  Traumatic  emphysema  accompanjing  fracture  of 
the  larynx  is  at  times  so  extensive  as  to  threaten  life  from  compres- 
sion of  the  larynx  or  trachea,  in  which  case  a  rapid  tracheotomy  is 
urgently  indicated.  Emphysema  following  puncture  of  the  lung  by 
a  sharp  fragment  of  a  broken  rib  often  spreads  very  rapidly  over  an 
extensive  surface  in  the  loose  subcutaneous  areolar  and  intermus- 
cular connective  tissue,  where  it  seldom  does  any  harm.  The 
emphysema  may,  however,  reach  through  the  subserous  connective 
tissue,  the  interlobular  connective  tissue  of  the  lung,  and  the  medi- 
astinum and  pericardium,  where  it  may  produce  distressing  symp- 
toms and  even  death  by  compression.  In  open  fractures  air  may 
be  aspirated  under  certain  conditions  which  create  suction,  but  in 
the  majority  of  ca.ses  of  emphysema  developing  in  connection  with 
comj)ound  fractures  some  time  after  the  accident  has  occurred,  the 
emphysema  is  caused  by  gas-formation,  one  of  the  gravest  indica- 
tions of  infection.  The  gas-generating  bacteria  are  bacilli  that  live 
on  dead  tissue,  and  the  emphysema  makes  its  appearance  after  the 
wound  has  become  the  seat  of  a  .secondary  mixed  infection  with 
putrcfictive  bacilli. 

Callus  Production. — A  study  of  callus  production  is  an  impor- 


352  FRACTURES. 

tant  introduction  to  a  consideration  of  the  manner  of  repair,  prog- 
nosis, and  treatment  of  fractures. 

Fractures  are  repaired  in  the  same  manner  as  wounds  of  the  soft 
tissues — that  is,  by  proHferation  of  preexisting  cells,  the  product  of 
which,  in  this  instance,  is  called  callus.  A  brief  historic  review 
of  this  subject  will  be  of  interest  to  illustrate  to  what  extent  the 
opinions  of  surgeons  regarding  the  mode  of  repair  after  fractures 
have  been  influenced  by  the  views  they  entertained  as  to  the  histo- 
logic source  from  which  the  reparative  material  is  derived. 

Galen,  who  wrote  quite  at  length  on  this  subject,  regarded  cal- 
lus as  a  substance  thrown  out  around  the  seat  of  fracture  for  the 
purpose  of  cementing  the  fragments  together,  without,  however, 
becoming  transformed  into  bone.  Van  Swieten  claimed  that  the 
cement  of  Galen  is  changed  into  bone.  J.  L.  Petit  compared  the 
healing  process  of  bone  with  the  repair  of  soft  tissues. 

Duhamel  de  Monceau  attributed  to  the  periosteum  and  endos- 
teum  the  function  of  producing  callus.  Haller,  and  his  prosector 
Detlef,  believed  that  the  periosteum  took  no  part  in  the  regeneration 
of  bone,  but  that  the  callus  is  derived  from  the  fractured  ends  of  the 
bones,  more  especially  the  myeloid  tissue.  Dupuytren,  from  a 
clinical  aspect,  revived  the  theory  of  Duhamel,  and  at  the  same 
time  assigned  bone-producing  qualities  to  the  soft  tissues  around 
the  seat  of  fracture.  He  also  introduced  the  terms  provisional  and 
definitive  callus.  He  claimed  that  the  definitive  callus  does  not 
make  its  appearance  until  four  or  five  months  after  the  injury,  and 
that  it  is  not  complete  before  from  eight  to  twelve  months. 

Cruveilhier  did  not  recognize  the  different  kinds  of  callus  de- 
scribed by  his  teacher,  and  ascribed  its  source  to  the  lacerated  soft 
parts  surrounding  the  fractured  bone-ends — the  periosteum,  con- 
nective tissue,  muscles,  tendons,  etc.  Bransby  B.  Cooper  defined 
callus  as  a  plastic  exudate  from  the  inflamed  ends  of  the  broken 
bone.  Lambron  asserted  that  a  broken  bone  can  unite  directly 
through  the  medium  of  an  interfragmentary  callus  without  the 
formation  of  a  provisional  callus.  P.  Flourens  believed  that  the 
periosteum  alone  is  capable  of  furnishing  material  for  new  bone. 
Subsequently,  however,  he  modified  his  view,  and  made  a  distinc- 
tion between  the  periosteal  or  permanent  callus,  and  the  temporary 
or  muscular  callus. 

August  Voetsch  speaks  of  callus  as  the  product  of  periosteitis. 
Rokitansky  taught  that  callus  is  developed  directly  from  bone  and 
its  connective  tissue,  including  the  periosteum.  Bernh.  Heine,  who 
has  studied  this  subject  with  great  care  by  means  of  the  microscope 
and  experimentally,  has  come  to  the  following  conclusions  :  The 
regeneration  of  broken  and  resected  bone  commences,  as  a  rule, 
from  connective  tissue.  The  process  of  regeneration  is,  at  times, 
limited  solely  to  the  connective  tissue  of  bone  and  periosteum,  but 
in  most  cases  the  connective  tissue  of  adjacent  parts,  more  especially 
the  muscles,  contributes  to  it. 


CALLUS    PRODUCTION.  353 

According  to  Virchow,  callus  is  produced  from  connective  tissue 
outside  of  the  bone,  as  well  as  from  myeloid  tissue  in  the  interior 
of  bone. 

Preparatory  to  his  studies  on  the  production  of  callus,  Hofmokl 
has  traced  the  histology  of  bone  during  fetal  life.  During  the 
development  of  bone,  cartilage  cells  are  transformed  into  bone-cells. 
The  primar\'  marrow  spaces  are  formed  in  the  interior  of  cartilage 
cells,  which,  with  their  contents,  are  transformed  into  marrow 
spaces.  The  normal  development  of  callus  appears,  histologically, 
as  a  return  of  perfect  bone  into  its  primary  stage,  embryonal  devel- 
opment. The  periosteum,  bone,  and  marrow  are  active  in  the  pro- 
duction of  callus.  The  neighboring  soft  tissues  assist  in  the  process 
of  repair  onh^  in  so  far  that  they  may  become  converted  into  bone. 
In  point  of  importance  the  callus-yielding  tissues  are  arranged  in 
the  following  order  :  periosteum,  marrow,  bone.  The  bone-cells 
take  an  essential  part  in  the  production  of  callus,  since  they  become 
enlarged,  multiply,  and  thus  form  marrow  spaces  with  myeloid  cells, 
changes  that  are  observed  very  distinctly  upon  the  surfaces  of  the 
ends  of  broken  bone,  on  the  periosteal,  as  well  as  on  the  medullary, 
side.  Ossification  invariably  begins  from  the  margins  of  a  medullary 
space. 

Gegenbauer  takes  the  ground  that  bone  is  produced  directly 
from  connective  tissue.  Sharpey's  fibers,  if  traced  carefully,  always 
spring  from  a  bony  point  between  the  Haversian  canals,  from  which 
point  the}'  radiate  toward  both  sides  into  the  lamellar  systems.  The 
fibers  form  networks,  and  at  points  of  intersection  bone-cells  are 
produced,  a  deposit  of  lamellae  taking  place  around  connective- 
tissue  fibers.  The  intercellular  substance  is  regarded  by  Gegen- 
bauer as  a  product  of  secretion  of  cell  elements,  and  not  as  a  meta- 
morphosis of  cells,  as  was  asserted  by  Waldeyer,  who  believed  that 
the  protoplasm  of  the  cells  is  transformed,  in  part  or  in  entirety, 
into  basis  substance. 

Kassowitz,  after  a  careful  study  of  the  process  of  ossification, 
has  come  to  the  conclusion  that  the  deposit  of  earthy  material  in 
the  fibrillary  reticulum,  as  well  as  in  the  osteoblasts,  is  dependent 
on  tiie  condition  of  the  circulation.  The  fact  that  the  immediate 
neighborhood  of  the  vessels  does  not  ossify  and  that  the  deposition 
of  earthy  material  occurs  in  advance  of  the  vessels  induced  him  to 
accept  the  theory  that  active  circulation  prevents  the  deposition  of 
earthy  material,  while  diminution  of  blood  pressure  favors  ossifi- 
cation. 

Rigal  and  Vignal's  experimental  researches  on  the  formation  of 
callus  have  an  important  and  direct  bearing  on  the  process  of  repair 
after  fractures.  Their  practical  deductions  may  be  summarized  as 
follows  : 

If  periosteum  is  exposed  to  a  moderate  degree  of  irritation,  new 
bone  is  j)roduced  from  the  marrow  beneath  the  point  of  irritation 
directly,  without  passing  thrcjugh  the  stage  of  cartilage.  If  irrita- 
23 


354 


FRACTURES. 


tion  is  increased  by  displacement  of  the  fragments  and  rubbing  of 
the  soft  parts,  the  result  is  cartilage  beneath  the  periosteum,  which 
is  subsequently  converted  into  bone.  If  the  periosteum  is  com- 
pletely destroyed  by  scraping  the  bone,  the  defect  is  repaired  by  a 
connective-tissue  cicatrix,  which  somewhat  resembles  periosteum. 
If  a  circular  piece  of  periosteum  has  been  removed,  and  the  bone 
is  broken  after  cicatrization  has  been  completed,  perfect  union  is  the 
result,  showing  that  bone  can  unite  independently  of  the  periosteum. 
If  the  cortical  layer  of  bone  is  scraped  or  chiseled  away  down  to 
the  medullary  canal,  the  defect  is  replaced  by  a  myeloid  callus.  If 
the  medullary  canal  is  not  opened,  the  process  of  regeneration  is 
slower,  as  a  considerable  period  of  time  will  elapse  until  the  result- 
ing rarefying  osteitis  opens  the  Haversian  canals  sufficiently  to 
furnish  the  required  amount  of  cellular  elements  from  the  medullary 
tissue  for  the  reparative  process. 

It  is  now  generally  conceded  that  the  provisional  or  temporary 


Fig.  212. — Bone  production  from  the  periosteum  (X  285)  :  a.  External  layer,  scanty 
in  cells  ;  b,  internal  layer,  rich  in  cells  (osteoplastic  layer  of  the  periosteum)  ;  c,  c,  osteo- 
blasts ;  d,  osteoid  tissue  (after  Weichselbaum). 


callus  is  the  product  of  the  periosteal  and  paraperiosteal  tissues, 
while  the  definite  or  permanent  callus  is  produced  directly  from  the 
osteoid  and  myeloid  tissues.  The  provisional  callus  is  nature's 
splint,  its  only  object  being  to  immobilize  the  parts  until  the  defin- 
itive callus  firmly  and  permanently  unites  the  fragments.  The 
temporary  callus  is  accidental,  and  appears  earliest  and  most 
copiously  where  paraperiosteal  tissues  are  most  abundant  and  mo- 
tion between  the  fragments  is  greatest ;  the  intermediate  or  perma- 
nent callus  is  produced  later,  and  is  most  certain  to  take  place  in 
spongy  bones.  Fractures  of  the  neck  of  the  femur,  partly  within 
and  partly  outside  the  capsule,  unite  with  as  much  certainty  as 
fractures  in  other  localities,  in  the  usual  way — by  the  formation  of 
external  and  intermediate  callus.  In  this  variety  of  fractures  an 
abundance  of  callus,  sometimes  bordering  on  deformity,  designates 


CALLUS    PRODUCTION. 


355 


>5 


the  exact  location  of  fracture.  In  intracapsular  fractures,  as  in 
fractures  within  any  other  joints,  the  conditions  for  the  formation 
of  external  callus  are  unfavorable  ;  hence  we  find  in  all  cases  pur- 
porting to  be  bony  union  imperfect,  if  any,  attempts  in  this  direc- 
tion. Anatonn-,  physiology,  and  experimental  research  all  tend  to 
prove  that  in  cases  of  intracapsular  fracture  we  have  all  the  condi- 
tions present  that  are  necessary  for  the  production  of  intermediate 
callus,  provided  the  fragments  are  kept  in  accurate  contact  for 
a  sufficient  length  of 
time.  ^ 

From  the  older 
writings  it  has  be- 
come apparent  that 
the  material  for  the 
repair  of  a  fracture 
is  derived  from  two 
sources,  the  perioste- 
um and  the  myeloid 
tissue.  That  the  peri- 
osteum takes  an  im- 
portant, if  not  an  es- 
sential, part  in  the 
process  of  bony  con- 
solidation of  a  frac- 
ture is  shown  by  ex- 
periments made  by 
Oilier.  He  removed 
the  periosteal  envelop 
of  the  entire  circum- 
ference of  the  shaft  of 
a  bone  in  a  rabbit, 
and,  after  healing  of 
the  wound,  fractured 
the  bone.  The  result 
was  a  very  tardy 
union,  which  required 
eight  weeks  for  its 
completion,  while 
fractures  made  in  animals  of  the  same  age  not  thus  treated  united 
firmly  in  two  weeks. 

Experiments  have  likcwi.se  shown  that  the  medullar}-  tissue  in 
the  central  canal  takes  an  active  part  in  the  repair  of  fractures  of 
the  shaft  of  the  long  bones,  and  that  the  red  marrow,  wherever 
found,  is  the  most  es.sential  agent  in  the  formation  of  the  interme- 
diary permanent  or  definitive  callus.  According  to  Gegenbauer, 
Waldeyer,  and  F.  Busch,  the  medullary  spaces  are  lined  with  cells 
that  can  be  recognized  as  remnants  of  osteoblasts,  which,  when 
subjected  to  irritation,  are  aroused  from  their  latent  condition  and 


Fig.  213. — Cartilaginous  and  Vjony  callus,  four  weeks 
after  fracture  of  the  coronoid  process  (X  285)  :  a.  Car- 
tilaginous callus;  b,  beginning  calcification  of  the  cartil- 
age and  direct  mass  forniaticjn  of  the  same  into  bone  ; 
c,  c,  bony  callus  ;  d,  d,  d,  medullary  spaces  (after  Weich- 
selbaum). 


356  FRACTURES. 

assume  active  tissue  proliferation.  Bruns  proved  the  osteogenetic 
capacity  of  the  medullary  tissue  by  his  transplantation  experiments. 
The  result  was  negative  in  69  experiments  in  which  he  transplanted 
the  marrow  from  one  animal  to  another.  Of  19  autotransplanta- 
tions,  12  proved  successful.  The  marrow  was  planted  in  localities 
devoid  of  tissue  capable  of  producing  bone  ;  hence  the  bone  forma- 
tion that  was  found  in  places  occupied  by  the  medullary  graft  could 
have  been  produced  only  by  the  myeloid  cells. 

The  histology  of  callus  formation  has  not  reached  perfection  : 
many  gaps  remain  which  must  be  filled  with  the  results  of  care- 
fully made  experiments  and  deductions  drawn  from  the  examina- 
tion of  specimens  from  the  human  subject. 

The  yellow  marrow  undergoes,  according  to  Oilier,  a  process 
of  rejuvenation  before  the  cells  can  take  an  active  part  in  the  pro- 
duction of  bone  ;  by  disappearance  of  the  fat-cells  and  proliferation 
of  the  myeloid  cells  the  yellow  marrow  again  resumes  its  embryonic 
appearance  and  juvenile  activity.  Authorities  differ  regarding  the 
transformation  of  the  product  of  proliferation  from  this  source  into 
bone  :  some  claim  it  is  transformed  directly  into  bone  ;  others  con- 
tend that  it  is  first  converted  into  cartilage  and  later  into  bone,  while 
still  others  claim  that  only  the  connective  tissue  of  the  marrow  takes 
an  active  part  in  the  production  of  bone.  Bruns  is  of  the  opinion 
that  bone  formation  from  the  product  of  medullary  proliferation 
occurs  in  a  direct  manner  by  the  formation  of  an  osteoid  substance, 
and  by  the  indirect,  through  a  preliminary  stage  of  cartilage  forma- 
tion. The  intra-osseous  callus,  from  proliferation  of  the  medullaiy 
tissue,  forms  in  a  remarkably  short  time,  as  has  been  shown  by 
Bruns,  Hilty,  and  Maas. 

The  intermediary  callus  plays  the  most  important  role  in  the 
process  of  bony  consolidation.  In  some  cases  the  provisional 
callus  appears  early  and  in  abundance,  but,  owing  to  the  tardiness  of 
the  formation  of  the  intermediary  callus,  bony  union  takes  place 
late,  and  sometimes  not  at  all ;  in  other  cases  the  intermediary 
callus  forms  early,  and  the  bone  unites  with  little  or  no  provisional 
callus.  The  osteoid  material  that  effects  the  bony  union  is  derived 
in  part  from  the  medullary  tissue  in  the  Haversian  canals,  and  in 
part  from  the  periosteum.  The  first  link  in  the  long  chain  of  tissue 
changes  that  occur  in  the  ends  of  the  fragments  during  the  process 
of  repair  is  the  stage  of  osteoporosis. 

The  osteoclasts  prepare  the  way  for  callus  formation.  The  in- 
creased vascularity  of  the  bone-ends,  so  constantly  present  during 
this  stage,  stimulates  the  cells  to  renewed  activity.  The  vascular 
spaces  and  medullary  canals  become  enlarged,  to  adapt  themselves 
to  the  increased  vascular  supply  and  for  the  reception  of  new  cells. 
With  the  transformation  of  the  new  material  into  bone  the  stage 
of  sclerosis  sets  in,  which  terminates  with  the  transformation  of  the 
callus  into  bone  and  the  completion  of  the  process  of  repair,  a  func- 
tion performed  exclusively  by  the  osteoblasts  in  the  medullary  tis- 


RESTORATION    OF    BONE. 


357 


sue  and  the  periosteum.  With  the  restoration  of  the  continuity  of 
the  bone  b)-  bony  consoUdation  the  temporarily  exaggerated  nu- 
tritive processes  subside,  and  much,  if  not  all,  of  the  provisional 
callus  disappears.  By  a  very  complicated  process  the  internal 
architecture  of  the  bone  is  restored,  in  a  manner  analogous  to  that 
■witnessed  during  the  growth  of  bone.  This  adds  strength  and 
durability  to  the  new  tissues  interposed  between  the  fragments,  and 
which  then  constitute  a  permanent  part  of  the  reunited  bone. 

The  Function  of  Detached  Fragments  in  the  Restoration  of 
the  Continuity  of  a  Broken  Bone. — In  the  discussion  of  com- 
pound fractures  great  stress  was  placed  on  the  importance  of  pre- 
serving detached  fragments  of  bone  in  all  cases  in  which  there  was 
reason  to  belie\'e  that  the  wound  was  or  could  be  made  aseptic. 
Convincing  reasons  were  given  to  substantiate  the  wisdom  of  pur- 
suing such  a  course.  It  is  well  known  that  in 
comminuted  fractures  the  detached  fragments 
do  not  act  as  foreign  substances,  but  are  incor- 
,  porated  in  the  callus  and  unquestionably  take 
acti\'e  part  in  the  process  of  repair.  It  is  im- 
portant to  follow  the  fate  of  such  loose  frag- 
ments of  bone,  more  especially  in  connection 
with  the  subject  of  intracapsular  fractures  of  the 
neck  of  the  femur,  radius,  and  humerus,  frac- 
tures in  which  the  detached  head  of  the  bone 
receives  little  or  no  blood  supply.  It  is  my 
intention  to  introduce  here  evidence  to  the 
effect  that,  even  in  the  event  of  the  detached 
piece  of  bone  being  entirely  deprived  tempo- 
rarily of  all  blood  supply,  union  by  bony  callus 
may  be  obtained  if  the  fractured  surfaces  are 
brought  at  once  in  accurate  contact  and  immo- 
bilized in  this  position  until  the  process  of  repair 
is  completed. 

In  fractures  of  the  neck  of  the  femur  the 
bone  has  usually  been  rendered  vascular  and 
porous  by  senile  osteoporosis,  and  its  medullary  spaces  have  been 
provided  with  an  abundance  of  myeloid  tissue  capable  of  bone  pro- 
duction. The  ves.sels  in  the  red  marrow,  according  to  recent  ob- 
servations, are  also  admirably  adapted  to  the  purpose  of  establishing 
early  and  free  collateral  circulation.  In  1869  Iloyer  made  the  dis- 
covery that  the  small  veins  in  the  red  marrow  are  without  walls, 
their  lumina  being  bounded  by  the  parenciiyma  of  the  marrow. 
Most  of  the  capillaries  are  also  without  walls.  The  small  arteries 
of  the  marrow  consist  of  a  delicate  tube  of  endothelium  and  a  single 
layer  of  muscle-fibers.  Rindfleisch  corroborated  these  observations. 
From  this  peculiar  structure  (^f  the  vessels  in  marrow,  it  is  easy 
to  conceive  how  readily  the  interrupted  circulation  could  be  restored 
through  direct  contact  of  the   severed  vessels,  or  by  canalization 


11  w^<< 


V  •^.^^^■>^.''>J--?l-.x.■i;'Jf/ 


Fig.  214. — United 
fracture  of  the  shaft  of 
the  femur,  showing  two 
fragments  of  the  com- 
pacta  embedded  in  the 
callus  (Bruns). 


358  FRACTURES. 

through  the  medium  of  a  blood-clot  or  mass  of  exudation  material. 
That  intermediate  callus  is  formed  in  cases  of  intracapsular  fractures 
where  the  fragments  have  not  been  kept  in  contact  and  bony  union 
has  failed  to  take  place  is  evident  from  examinations  made  of  speci- 
mens where  the  broken  surface  of  the  upper  fragment,  and  some- 
times the  connecting  ligamentous  band,  presented  well-marked 
spurs  of  hard,  compact  bone,  a  condition  alluded  to  by  many 
observers,  but  more  particularly  by  Sir  Astley  Cooper  and  Mr.  Mac- 
Namara.  It  has  been  urged  against  the  possibility  of  bony  union 
after  intracapsular  fractures  that  the  upper  fragment  is  not  furnished 
with  a  blood  supply  sufficient  to  maintain  nutrition,  much  less  to 
produce  callus.  Clinical  and  postmortem  evidence,  however,  tends 
to  prove  that,  in  the  great  majority  of  cases,  the  fragment  retains 
its  vitality,  and  in  many  instances  where  bony  union  has  failed  to 
take  place  the  fractured  surface  shows  evidence  of  callus  production. 
In  such  cases,  where  the  fracture  was  complete  and  the  fibrous  in- 
vestment of  the  neck  was  completely  torn  across,  the  requisite  vas- 
cular supply  must  have  been  furnished  through  the  round  ligament. 
If  the  upper  fragment  was  not  nourished  from  some  source,  it  would 
more  frequently  disappear  by  absorption,  suffer  necrosis,  and  act  as 
a  foreign  body  than  has  been  actually  observed  at  the  bedside  or  in 
the  postmortem  room.  The  establishment  of  collateral  circulation 
through  the  ligamentum  teres,  in  maintaining  the  vitality  of  the 
upper  fragment  after  intracapsular  fractures,  is,  unquestionably,  of 
more  frequent  occurrence  and  of  greater  importance  than  many  are 
ready  to  admit. 

Taking  it  for  granted,  however,  that  the  ligamentum  teres  fur- 
nishes no  vessels  to  the  upper  fragment,  it  can  nevertheless  be 
shown  that  in  case  of  impaction  it  can  retain  its  vitality,  assist  in  the 
formation  of  callus,  and  enter  into  the  production  of  bony  union. 
It  has  been  known  for  a  long  time  that,  in  compound  fractures,  per- 
fectly detached  splinters  remain  innocuous  and  assist  in  the  produc- 
tion of  bony  callus  without  giving  rise  to  any  particular  symptoms 
of  irritation.  John  Hunter  expressed  himself  as  follows  on  this 
subject :  "Adhesion  of  the  detached  splinters  also  takes  place,  not 
only  in  those  which  are  attached  to  the  soft  parts,  but  even  such  as 
are  entirely  loose.  (This  was  shown  in  a  thigh  bone  in  which  one 
of  the  splinters  had  moved  quite  around  on  its  axis  and  adhered  by 
its  outer  surface  to  the  bone.)  I  never  examined  a  compound  frac- 
ture without  finding  some  of  those  loose  pieces,  which  shows  they 
must  be  common.  Their  union  must  be  similar  to  that  in  the 
transplanted  teeth." 

Oilier  and  Philip  Walther  inform  us  that  they  have  seen  the 
disc  of  bone  separated  by  the  crown  of  the  trephine,  and,  entirely 
removed,  reunite  with  the  surrounding  bone  when  replaced. 

Prince,  in  speaking  of  the  drilling  operation  for  ununited  frac- 
tures, says  :  "  When  the  operation  results  in  the  effusion  of  plastic 
lymph  without  suppuration,  there  are  new  centers  of  ossification  in 


RESTORATION    OF    BONE.  359 

the  chips  of  bone  cut  off  by  the  drill.  These  are  left  in  the  track 
of  the  drill  :  some  of  them  in  the  soft  callus  between  the  ends  of 
the  fragments.  That  these  minute  fragments  of  bone  become  parts 
of  the  living  tissue  is  certain  ;  for  if  they  did  not,  they  would,  by 
the  offensive  emanations  of  dead  bone,  excite  suppuration  and  work 
their  way  to  the  exterior.  The  importance  of  these  little  fragments 
cut  off  by  the  drill  as  centers  of  ossification  ma\^  have  received  too 
little  attention."  Cases  where  fragments  of  bone  from  the  internal 
table  of  the  skull  were  completely  detached  and  yet  united  with  the 
surrounding  bone  by  permanent  callus  are  reported  by  Samuel 
Thomas,  Soemmering,  B.  Beck,  von  Bergmann,  H.  Demme,  Clus- 
ton,  Richet,  Ziegler,  and  others. 

Lossen  has  studied  this  subject  in  connection  with  comminuted 
fractures  of  the  long  bones,  and  has  come  to  the  conclusion  that 
not  all  loose  fragments  necrose,  but  that  in  many  instances  they  are 
incorporated  in  the  callus  and  form  part  of  the  living  bridge  between 
the  fractured  ends.  He  is  of  the  opinion  that  the  vessels  of  the 
fragment  unite  at  some  point  with  the  vessels  in  the  lacerated  dis- 
trict, thus  establishing  the  circulation.  In  one  of  his  illustrations 
may  be  seen  a  fragment,  five  centimeters  long  and  one  centimeter 
broad,  completely  isolated  and  denuded  of  its  periosteum,  which, 
with  its  wedge-shaped  end,  had  been  driven  into  the  medullary 
canal.  The  upper  end  was  perfectly  united  with  the  bony  mass 
filling  the  medullary  cavity,  and  its  lower  end  could  be  seen  along- 
side of  the  necrotic  portion  of  the  fractured  bone.  It  can  be  safely 
taken  for  granted  in  this  instance  that  the  vessels  in  the  medullary 
canal  vascularized  the  fragment  and  preserved  its  vitalit}'.  Klebs 
gives  a  description  of  a  similar  specimen,  and  believes  that  the 
vitality  of  the  medullary  tissue  and  periosteum  is  sufficient  to  sus- 
tain the  physiologic  activity  of  isolated  fragments  under  favorable 
circumstances,  production  of  new  bone  taking  place  from  the  isolated 
transplanted  fragment. 

Von  Bergmann  describes  a  specimen  of  comminuted  fracture  of 
the  femur  the  result  of  a  gunshot  wound  during  the  Turko-Russian 
war,  where  a  fragment  7.2  cm.  long,  15  mm.  broad,  and  6  mm. 
thick  had  become  completely  detached  from  the  soft  tissues,  and 
had  been  forced  into  the  medullary  cavity,  where  it  became  firmly 
united  with  the  fractured  ends  of  the  bone  and  the  intervening  bony 
callus. 

Meek'ren  made  a  series  of  experiments  on  animals  for  the  pur- 
po.se  of  establishing  the  fact  that  isolated  fragments  of  bone  devoid 
of  periosteum  would,  under  certain  favorable  conditions,  retain  their 
vitality,  and  were  capable  of  forming  an  attachment  to  bone  through 
the  intervention  of  a  bony  callus.  He  removed,  by  the  trephine, 
from  the  skull  of  a  dog,  a  disc  of  bone  and  replaced  it.  On  the 
twenty-second  day  lie  found  this  disc  firmly  united  by  bony  callus 
to  the  surrounding  bone. 

J'"lourens  transplanted  a  piece  of  rib  from  a  dog  under  the  peri- 


360    ■  FRACTURES. 

osteum  of  the  tibia  of  the  same  animal,  and  in  due  time  found  it 
united  by  bony  callus.  The  well-known  experiments  of  Oilier  are 
familiar  to  every  surgeon,  but  as  he  placed  great  importance  on  the 
preservation  of  the  periosteum  as  an  essential  condition  for  success 
in  bone  transplantation,  they  are  not  of  great  importance  for  our 
purpose.  The  experiments  of  Kosmowski,  to  ascertain  the  exact 
mode  of  repair  in  cases  of  fracture  of  the  skull,  indicate  that  the 
reparative  process  in  general,  and  the  union  of  loose  splinters  of 
bone  in  particular,  are  accomplished  through  the  osteogenetic  func- 
tions of  the  medullary  tissue. 

Of  great  practical  importance  are  the  experiments  of  Jakim- 
owitsch.  The  experiments  were  made  exclusively  on  the  long 
bones  of  dogs,  and  the  vascular  connections  of  the  transplanted  or 
replanted  piece  of  bone  were  demonstrated  by  means  of  gelatin 
injections  stained  with  Berlin  blue.  To  insure  success,  he  places 
great  importance  on  securing  accurate  apposition  and  perfect  im- 
mobilization of  the  fragment  by  stitching  the  periosteum  or  soft  parts 
over  it,  and  applying  elastic  pressure  and  a  fixation  splint  of  plaster- 
of-Paris.  The  operation  was  always  done  under  strict  aseptic  pre- 
cautions. 

To  prove  that  the  detached  bone  had  become  part  and  parcel 
of  the  living  bone,  some  of  the  animals  were  fed  on  madder,  after 
the  example  of  J.  Wolff.  This  staining  material  is  deposited,  during 
life,  in  the  new  bone  in  greatest  abundance  around  the  fragment, 
while  it  also  follows  the  new  vessels  into  the  transplanted  piece. 
In  almost  all  the  cases,  after  death  the  vessels  of  the  limb  operated 
upon  were  injected  with  gelatin  stained  with  Berlin  blue,  which 
afforded  an  excellent  opportunity  to  follow  the  course  of  the  ves- 
sels into  the  transplanted  or  replanted  piece  of  bone.  In  other 
instances  the  examination  was  made  even  more  complete  by  decal- 
cifying the  bone  and  subjecting  it,  in  numerous  sections,  to  micro- 
scopic examination.  The  results  of  these  experiments  induced  him 
to  conclude  that  replantation  and  transplantation  of  isolated  frag- 
ments of  bone  can  be  successfully  performed  if  the  detached  piece 
retains  its  former  relations  to  its  immediate  vicinity.  Under  such 
conditions  the  piece  of  bone  becomes  a  living  part  of  the  bone 
through  the  medium  of  an  intermediate  callus  and  the  reestablish- 
ment  of  vascular  connections. 

Gurlt  describes  and  furnishes  illustrations  of  two  specimens  of 
fracture  of  the  femur  in  which  a  large  fragment  of  the  cortical  layer 
near  the  center  of  the  shaft  had  become  entirely  detached,  and  in 
one  instance  turned  completely  around,  and  yet  they  were  found 
firmly  attached  by  bony  union,  He  states,  further,  that  in  commi- 
nuted fractures,  where  many  loose  fragments  must  exist,  they  fur- 
nish no  obstacle  to  ready  bony  union. 

McEwen  resorted  to  transplantation  of  small  pieces  of  bone  to 
restore  extensive  pathologic  defects,  believing  that  the  blood-clot 
between  the  fragments  served  as  a  medium  through  which  the  vas- 


RESTORATION    OF    BONE.  36 1 

cular  connection  between  the  detached  bone  and  surrounding  tissues 
is  estabhshed.  He  operated  successfully  upon  a  case  of  necrosis  of 
the  humerus,  with  extensive  loss  of  bone  substance,  by  transplant- 
ing into  a  groove  made  in  the  bone  numerous  wedge-shaped  pieces 
of  bone  derived  from  the  tibiae  of  six  rickety  children,  the  fragments 
being  supplied  with  periosteum  and  marrow  tissue.  The  bone  grafts 
retained  their  vitality  and  united  with  and  grew  with  the  bone. 

Professor  von  Nussbaum  has  introduced  transplantation  of  bon^ 
as  a  legitimate  operation  in  surgery,  for  the  purpose  of  supplying 
bone  defect  in  cases  of  ununited  fracture,  and  his  success,  as  well 
as  similar  operations  by  several  other  German  surgeons,  certainly 
proves  that  the  vitality  of  even  compact  bone  is  sustained  by  a 
minimum  amount  of  blood  supply  through  a  narrow  strip  of  peri- 
osteum. 

Spongy  bone,  containing  an  abundance  of  marrow  tissue  and  a 
rich  supply  of  blood-vessels,  is  endowed  with  a  higher  degree  of 
vitality  than  compact  bone,  and  is,  consequently,  better  adapted  to 
enter  into  union  with  surrounding  tissues  in  case  it  has  become 
detached. 

It  has  also  been  established,  by  way  of  experiment,  that  in 
animals  marrow  can  be  transferred  to  different  parts  of  the  body, 
and,  if  the  operation  is  successful,  the  transplanted  marrow  will 
produce  bone. 

Baikow,  Goujon,  and  Oilier  were  successful  in  their  autotrans- 
plantation  of  marrow,  but  failed  when  the  tissue  was  transferred 
from  one  animal  to  another.  The  most  extensive  and  reliable  ex- 
periments on  marrow  transplantation  have  been  made  by  P.  Bruns. 
He  operated  upon  sixty  chickens  and  six  dogs.  He  failed  repeat- 
edly as  long  as  he  transplanted  the  marrow  from  animal  to  animal, 
but  as  soon  as  he  limited  his  experiments  to  autotransplantation,  he 
succeeded  in  the  great  majority  of  cases.  Of  19  autotransplanta- 
tions,  12  proved  succes.sful,  3  failed  on  account  of  suppurative  in- 
flammation following  the  operation,  and  in  4  the  transplanted  tissue 
was  absorbed. 

The  operation  consisted  in  removing  cylindric  pieces  of  marrow 
from  the  femur  or  tibia,  from  one-half  to  an  inch  and  a  half  in 
length,  and  transplanting  them  under  the  skin  of  the  same  animal. 
After  the  fourteenth  day  foci  of  ossification  could  be  distinctly  seen, 
which  enlarged  and  became  confluent  after  the  twentieth  to  the 
twenty-fourth  day.  Ossification  was  preceded  by  an  active  prolifera- 
tion of  spindle-shaped  cells.  The  formation  of  bone  took  place 
from  preexisting  osteoblasts  in  the  marrow,  an  observation  strongly 
supported  by  Waldcyer.  The  yellow  and  red  marrows  were  used 
in  these  experiments,  and  proved  alike  capable  of  producing  bone 
in  their  new  location. 

The  success  that  attended  the  transplantation  of  bone  and 
medullary  tissue  a  number  of  years  ago  has  been  increased  by 
recent  efforts  in   the  .same  direction,  and  fully  corroborated  in  the 


362  FRACTURES. 

human  subject  by  ample  clinical  experience.  Elsewhere  I  have 
detailed  the  results  of  my  observations  and  experience  on  the  same 
subject,  which  have  convinced  me,  more  than  ever  before,  that  com- 
pletely detached  fragments  and  portions  of  bone  in  aseptic  environ- 
ments, kept  in  contact  with  vascular  surroundings,  will  live  and 
take  an  active  part  in  the  subsequent  process  of  repair.  The  suc- 
cess attending  bone  and  marrow  transplantation  constitutes  a  strong 
argument  in  favor,  not  only  of  the  possibility,  but  also  of  the  proba- 
bility, of  bony  union  after  intracapsular  fractures,  in  the  event  of  the 
fractured  ends  being  in  accurate  and  undisturbed  contact  for  the 
requisite  length  of  time. 

The  neck  of  the  femur  in  a  state  of  senile  osteoporosis  furnishes 
a  number  of  favorable  conditions  for  a  speedy  production  of  bony 
callus.  It  is  very  vascular,  the  compacta  is  attenuated,  the  spon- 
giosa  is  exceedingly  porous,  and  its  meshes  are  filled  with  an 
abundance  of  myeloid  tissue  fully  capable,  in  the  event  of  injury,  of 
assuming  active  tissue  proliferation.  If  perfectly  detached  pieces 
of  bone,  devoid  of  periosteum,  and  isolated  masses  of  marrow  can 
be  transferred  to  a  distant  part  of  the  body,  and,  when  properly 
transplanted,  not  only  retain  their  vitality,  but  also  are  vascularized 
and  produce  bone,  there  is  no  reason  why  the  upper  fragment  in 
intracapsular  fractures,  which  is  retained  in  its  normal  location, 
should  not  possess  the  same  power  of  self-preservation  and  repair, 
inasmuch  as  it  receives  at  least  a  feeble  blood  supply  through  the 
ligamentum  teres. 

In  impacted  fractures  the  bone  tissue,  marrow,  and  lacerated 
vessels  are  brought  in  such  immediate  contact  that  the  reparative 
process  is  taxed  only  to  its  minimum  extent  in  restoring  the  con- 
tinuity of  the  bone.  In  these  instances  we  have  an  example  of  bone 
and  marrow  transplantation  under  the  most  favorable  conditions, 
and  the  reason  such  transplantation  does  not  succeed  oftener,  is 
simply  because  these  favorable  conditions,  as  a  rule,  do  not  exist 
(unimpacted  fractures)  or  are  not  maintained  for  a  sufficient  length 
of  time  (impacted  fractures). 

Prognosis. — The  prognosis  of  subcutaneous  fractures  has  ref- 
erence to  the  preservation  of  life  and  the  functional  utility  of  the 
limb.  The  danger  to  life  depends  almost  exclusively  on  the  pres- 
ence of  complications,  as  the  fracture  or  fractures  themselves  are 
very  seldom  an  immediate  or  a  remote  cause  of  death  if  we  exclude 
fractures  of  the  skull,  in  which  case  a  deep  depression  may  in  itself 
become  a  source  of  danger  to  life.  As  the  immediate  and  sole 
cause  of  death  in  fractures  of  any  other  bones  except  those  of  the 
skull,  must  be  mentioned  the  very  rare  cases  of  death  from  fat  em- 
bolism. In  the  remaining  cases  danger  to  life  may  arise  from  com- 
plications caused  by  the  fracturing  force  or  by  displaced  fragments. 
In  this  respect  fractures  of  the  skull,  vertebrae,  hyoid  bone,  larynx, 
sternum,  ribs,  and  pelvis  are  attended  by  the  greatest  probability  of 
being  complicated  by  dangerous  lesions  of  important  organs. 


PROGNOSIS.  363 

In  crushing  injuries  shock  enters  as  an  element  of  danger  to 
life.  Wounds  of  large  blood-vessels  complicating  a  fracture  may 
result  in  death  from  hemorrhage  or  in  fractures  of  the  skull  from 
cerebral  compression.  In  complicated  fractures  wounds  of  large 
blood-vessels  and  injuries  of  the  principal  nerve-trunks  may  become 
a  source  of  danger  to  limb  and  life  from  gangrene.  The  danger 
to  life  from  compound  fractures  lies  almost  exclusively  in  the  extent 
and  nature  of  the  complicating  wound.  The  antiseptic  treatment  as 
employed  to-day  has  succeeded  in  reducing  the  mortality  from  this 
cause  enormously,  but  the  most  careful  treatment  has  not  suc- 
ceeded, even  in  the  hands  of  the  most  competent  surgeons  and 
with  the  best  facilities  for  securing  asepsis,  in  reducing  the  mortality 
of  compound  fractures  to  that  of  subcutaneous  fractures,  indepen- 
dently of  the  danger  arising  from  the  wound  per  sc,  as  the  most 
rigid  antiseptic  precautions  practised  immediately  or  soon  after  the 
wound  has  been  received  do  not  always  prove  successful  in  averting 
infection.  Delirium  tremens  and  nervosum,  hypostatic  pneumonia, 
and  decubitus  are  dangers  common  to  open  and  subcutaneous  frac- 
tures. Tetanus  as  a  complication  due  to  fracture  can  only  occur  in 
connection  with  compound  fracture  ;  if,  in  very  exceptional  instances, 
it  attacks  a  patient  suffering  from  a  subcutaneous  fracture,  infection 
takes  place  through  a  wound  of  the  skin  distant  from  the  seat  of 
fracture. 

In  compound  fractures  the  preservation  of  the  limb  depends 
almost  entirely  upon  the  extent  and  nature  of  the  injury  of  the  soft 
tissues,  instead  of  upon  the  extent  of  the  bone  injury.  Primary 
amputation  for  compound  fractures  has  become  very  rare,  except  in 
cases  in  which  the  limb  has  been  rendered  lifeless  by  a  crushing 
injur>^  In  subcutaneous  fractures  a  primary  amputation  is  seldom, 
if  ever,  justifiable,  even  should  the  injury  be  complicated  by  a  wound 
of  a  large  blood-vessel.  In  such  cases  it  would  be  the  duty  of  the 
surgeon  to  resort  to  ligation,  if  need  be,  and  await  the  effect  of  the 
vessel  injury  on  the  nutrition  of  the  limb,  and  resort  to  a  secondary 
amputation  should  gangrene  set  in.  Exaviiiiation  for  vessel  and 
nerve  injury  is  as  important  in  subcutaneous  as  in  compound  fractures , 
and  shoidd  never  be  neglected,  as  the  only  danger  to  the  limb  in  closed 
fractures  arises  from  this  source,  and  unless  the  physician  recognizes 
the  nature  of  the  complication  early  and  is  able  to  predict  the  probable 
residt,  the  patient  and  his  friends  are  only  too  ready  to  blame  the  treat- 
ment and  not  the  injury  shoidd  gangrene  occur. 

Satisfactory  union  of  the  fracture  and  restoration  of  function 
are  influenced  by  many  conditions  with  which  the  physician  should 
famiiiari/.c  himself  on  taking  charge  of  the  case.  Fractures  caused 
by  direct  force,  on  the  whole,  are  more  serious  injuries  than  indirect 
fractures.  This  is  true  of  open  as  well  as  of  subcutaneous  frac- 
tures. The  seat  of  the  fracture  has  an  important  bearing  on  the 
process  of  repair  and  on  the  subsecjucnt  utility  of  the  limb.  Frac- 
tures of  bones  that  include  and  protect  iinjxjrtant  organs  are  always 


364  FRACTURES. 

serious  injuries.  Short  and  flat  bones  present  the  most  favorable 
conditions  for  speedy  and  satisfactory  union,  as  there  is  but  sHght 
tendency  to  displacement,  union  taking  place  almost  exclusively 
by  intermediate  callus,  produced  by  the  myeloid  tissue,  so  richly 
stored  in  the  porous  spongiosa.  Reverse  conditions  are  presented 
by  fractures  of  the  long  bones  when  the  tendency  to  displacement 
is  great,  and  the  dense  thick  compacta  must  undergo  osteoporosis 
preliminary  to  the  process  of  repair  by  callus  formation.  On  the 
whole,  fractures  of  the  lower  extremity  do  not  yield  so  good 
results  as  fractures  of  the  upper  extremity,  as  the  mechanical  diffi- 
culties encountered  in  their  treatment  are  much  greater.  Fractures 
of  the  lower  extremity  are  likewise  more  dangerous  to  life,  from 
incidental  causes,  as  they  require  a  longer  period  of  recumbency  in 
their  treatment.  Fractures  of  the  shaft  of  the  long  bones  yield 
better  functional  results  than  fractures  of  the  epiphyseal  extremi- 
ties, owing  to  the  proximity  of  the  latter  to  joints,  which  are  often 
invaded  by  the  fracture  or,  at  least,  injured  by  the  fracturing  force. 
Moreover,  the  prolonged  rest  of  the  joint  during  the  treatment 
of  the  fracture  is  prone  to  impair  for  a  long  time,  or  permanently, 
the  function  of  the  joint. 

Fracture  of  one  bone  of  the  forearm  or  leg  is  followed  by  a 
better  result  than  fracture  of  both  bones,  as  in  the  former  instance 
the  remaining  bone  serves  as  a  splint,  antagonizing  longitudinal 
displacement  and  securing  rest  for  the  seat  of  injury. 

Impacted  fractures,  if  the  limb  is  in  a  useful  position,  heal  by 
bony  consolidation  in  a  very  short  time  if  the  impaction  remains  or 
is  maintained  by  an  appropriate  mechanical  support. 

The  prognosis  as  to  the  time  of  healing  and  to  functional  result 
is  better  in  transverse  than  in  oblique  fractures,  for  the  reason  that, 
when  the  fragments  are  placed  in  proper  position,  shortening 
can  not  occur,  angular  deformity  can  be  prevented  by  the  simplest 
mechanical  treatment,  and  accurate  contact  between  the  fractured 
surfaces  is  the  best  guarantee  for  a  speedy  union  by  a  minimal 
intermediate  callus.  Comminuted  fractures,  especially  such  as  ex- 
tend into  the  joint,  often  tax  the  surgeon's  ingenuity  to  its  utmost 
in  maintaining  the  fragments  in  proper  position,  unsatisfactory 
results,  nevertheless,  occurring  in  the  practice  of  the  most  expert 
surgeons.  It  is  also  in  this  class  of  cases  that,  in  spite  of  most 
efficient  mechanical  treatment,  a  massive  provisional  callus  forms 
that  not  infrequently  permanently  impairs  joint  motion,  and  in 
which  nerves,  muscles,  and  tendons  may  become  embedded — re- 
mote conditions  that  impair  permanently  the  usefulness  of  the  limb. 

Diastasis,  or  separation  of  the  fragments  in  the  axis  of  the  limb, 
as  is  the  case  in  fractures  of  the  patella  and  olecranon  process,  is 
the  most  unfavorable  condition  for  obtaining  union  by  bony  con- 
solidation without  direct  means  of  fixation.  Union  by  a  short 
ligamentous  band,  the  usual  result  obtainable  by  any  known 
methods  of  treatment  short  of  operative  interference,  usually  yields 


GENERAL    TREATMENT. 


365 


a  satisfacton',  if  not  a  perfect,  functional  result.  Repair  of  frac- 
tures in  children  takes  place  very  rapidly, — in  one-half  of  the  time 
required  in  adults, — and  the  functional  results,  as  a  rule,  are  better, 
as  muscular  contraction  is 
less  pronounced  and  cor- 
rection of  deformities  aris- 
ing from  the  fracture  takes 
place  more  completely  dur- 
ing the  bone-growing  period 
of  life  than  in  the  adult  or 
the  aged. 

The  general  condition  of 
the  patient  has  very  little 
bearing  on  the  repair  of 
fractures,  as  union  by  bony 
callus  takes  place  in  the 
weak  as  readily  as  in  the 
strong,  and  in  osteoporotic 
and  softened  bones  as  fa- 
vorabl}'  as  in  bones  of  nor- 
mal texture  and  resistance. 
Finally,  the  functional  result 
in  all  cases  of  fractures,  un- 
influenced, as  it  is,  by  vari- 
ous conditions,  depends  very 
largely  on  the  accuracy  with 
which  the  diagnosis  is  made, 
the  care  exercised  in  effect- 
ing complete  reduction,  the 
mechanical  skill  emi^loyed 
in  the  treatment,  and  the 
degree  of  vigilance  brought 
to  bear  from  the  time  the 
injury  was  received  until  the  maximum  obtainable  function  com- 
patible with  the  nature  of  the  injury  is  secured. 

GENERAL  TREATMENT. 

The  physician  who  masters  the  principles  that  govern  the  gen- 
eral treatment  of  fractures  is  best  prepared  to  aj)pl\'  his  knowledge 
in  the  management  of  special  cases,  while  the  one  who  is  familiar 
with  prescribed  rules  for  special  cases  and  who  loses  sight  of  the 
general  principles  upon  which  thc\^  are  based  is  very  apt  to  make 
.serious  mistakes  of  omission  and  conmiission  in  following  out  the 
details  of  treatment.  The  successful  treatment  of  a  difficult  frac- 
ture depends  on  a  thorough  knowledge  of  anatomy,  including  the 
mechanism  of  muscular  action  in  effecting  displacement  of  frag- 
ments, an  accurate  diagnosis,  com[)lete  reduction  of  the  dislocated 
fragments,  the  emj;l(jyment  of  efficient  and  safe  methods  of  fixa- 


Fig.  215. — Fracture  of  the  olecranon,  with 
great  retraction  of  upper  fragment  by  the  triceps 
muscle. 


366  FRACTURES. 

tion,  and  constant  care  and  watchfulness  in  averting  complications, 
and,  after  the  fracture  has  united,  persistent  efforts  to  restore  func- 
tion. The  public  and,  it  may  be  safely  said,  many  members  of 
the  profession  still  entertain  the  erroneous  impression  that  the  most 
important  functions  of  the  surgeon  consist  in  setting  and  dressing 
the  fracture ;  once  set  and  properly  dressed,  a  good  result  is 
expected  as  a  matter  of  course.  The  knowledge  necessary  to  make 
a  correct  diagnosis,  which  should  necessarily  precede  all  attempts 
at  reduction  and  fixation  of  the  fracture,  the  endless  difficulties  in 
keeping  the  fragments  in  correct  position,  the  complications  that 
accompany  so  many  fractures,  and  the  persistent  efforts  so  often 
necessary  to  restore  function  are  seldom  adequately  estimated  ;  and 
yet  they  constitute  very  essential  features  in  the  rational  and  suc- 
cessful treatment  of  fractures. 

The  first  duties  of  the  surgeon  in  the  treatment  of  subcutaneous 
fractures  consist  in  meeting  the  indications  presented  by  the  imme- 
diate effects  of  the  injury,  applying  the  first  dressing,  superintending 
the  transportation  of  the  patient,  and,  in  fractures  of  the  lower 
extremity  requiring  confinement  in  bed,  in  supervising  the  con- 
struction of  a  bed  that  will  be  adapted  to  the  mechanical  treatment 
of  the  fracture  without  exposing  the  patient  unnecessarily  to  the 
immediate  discomforts  and  remote  consequences  of  decubitus.  If 
the  patient  is  suffering  from  shock,  rest  in  the  recumbent  position 
and  stimulation  are  relied  upon  in  counteracting  the  immediate 
effects  of  the  injury,  while  the  limb  is  placed  in  a  comfortable  posi- 
tion until  the  patient  has  recovered  sufficiently  to  permit  examina- 
tion and  the  application  of  the  first  dressing.  If  the  patient  is 
examined  at  the  place  of  injury,  a  thorough  examination  and  per- 
manent dressing  are  not  made  until  he  has  reached  his  destination, 
— a  hospital,  his  home,  or  a  boarding-house, — because  during  the 
transportation  the  fragments  are  very  liable  to  become  displaced 
and  the  permanent  dressing  may  do  more  harm  than  good  by 
making  harmful  pressure  and  by  interfering  with  the  free  peripheral 
circulation.  This  precaution  applies  more  particularly  to  fractures 
of  the  lower  extremity.  Fractures  of  the  ribs,  scapula,  clavicle, 
and  most  of  the  fractures  of  the  arm  and  forearm  can  be  at  once 
subjected  to  the  necessary  thorough  examination,  and  if  readily 
reduced,  they  are  immobilized  before  the  patient  is  transported.  In 
fractures  of  the  lower  extremity  above  the  ankle-joint  it  is  advisable 
to  ascertain  the  existence  and  probable  location  of  the  fracture, 
bring  the  fragments  in  such  a  position  that  no  injury  will  arise  from 
them  during  the  transportation,  and  apply  a  provisional  dressing 
that  will  immobilize  the  limb  without  exposing  it  to  the  risk  of 
harmful  localized  or  circular  compression.  In  fractures  of  the  spine 
even  the  lifting  of  the  patient  requires  attention  and  care.  Flexion 
of  the  spine  and  lateral  deviations  must  be  carefully  avoided,  as 
such  movements  might  displace  fragments  in  the  direction  of  the 
cord  sufficiently  to  cause  dangerous  compression,  if  not  laceration 


GENERAL    TREATMENT.  367 

or  crushing,  of  the  cord.  The  lower  extremity  can  be  safely 
immobilized  by  wrapping  a  pillow  or  blanket  around  it,  and  by 
supporting"  it  with  two  lateral  splints  tied  together  with  just  suffi- 
cient firmness  practically  to  immobilize  the  fractured  bone.  If  not 
at  hand,  a  stretcher  can  be  improvised  with  the  aid  of  a  blanket,  a 
sheet,  an  overcoat,  or  one  or  more  empt}'  flour  bags,  and  two  poles 
or  sticks,  from  two  to  four  feet  longer  than  the  patient.  Stretcher 
transportation  is  much  more  comfortable  for  the  patient  than  riding 
in  a  wagon  if  the  distance  is  not  too  great.  If  the  patient  is  trans- 
ported by  wagon  or  railway  train,  he  should  be  placed  flat  on  his 
back  on  a  mattress,  with  the  head  only  slightly  elevated,  as  this 
position  is  the  one  that  secures  relaxation  of  all  muscles  and,  con- 
sequently, rest  for  the  entire  body  as  well  as  for  the  injured  limb. 
In  lifting  patients  suffering  from  fracture  of  the  lower  extremity 
upon  and  from  the  stretcher  or  wagon,  the  uninjured  limb  should 
be  used  as  a  temporary  splint,  as  otherwise  the  patient's  attempt 
to  support  it,  or  the  carrier's  effort  to  lift  it,  will  disturb  the 
injured  limb. 

The  physician  who  has  mechanical  skill  and  good  sound  judg- 
ment will  have  no  difficulty  in  extemporizing  dressings  from  the  sim- 
plest materials,  and  so  conduct  the  transportation  that  the  fractured 
bone  does  not  become  a  source  of  danger.  A  fractured  humerus 
can  be  safely  immobilized  by  bandaging  the  arm  loosely  to  the  side 
of  the  chest,  placing  a  small  pillow  or  compress  between  the  arm 
and  the  chest-wall,  and  putting  the  forearm  in  a  sling.  Patients 
with  a  fracture  of  both  bones  of  the  forearm  can  be  made  comfort- 
able during  the  transportation  by  applying  a  well-padded  splint, 
extending  from  the  bend  of  the  elbow  to  the  base  of  the  fingers, 
over  either  the  flexor  or  extensor  side,  and  placing  the  forearm  in  a 
sling  at  a  right  angle,  half-way  between  pronation  and  supination. 

A  fractured  rib  ca^i  be  immobilized  by  pinning  the  undershirt 
or  vest  tightly  around  the  chest.  As  soon  as  the  patient  has 
reached  his  destination,  preparations  must  be  made  for  the  final 
examination  and  for  his  comfort  during  his  confinement.  The 
former  necessitates  removal  of  the  clothing  ;  the  latter,  proper  con- 
struction and  preparation  of  the  bed.  In  making  an  examination 
for  fracture  of  the  upper  extremities,  chest,  and  spine  it  is  necessary 
to  remove  the  clothing  as  far  as  the  pelvis  ;  in  examining  for 
fracture  of  the  remaining  bones  the  pelvis  and  lower  extremities 
must  be  exposed.  Removal  of  clothing  to  this  extent  is  necessary 
for  the  purpose  of  making  comparisons  by  inspection,  palpation, 
and  mensurations  between  tiie  two  sides.  Grave  mistakes  in  diag- 
nosis have  been  committed  by  not  taking  the  necessary  precaution 
to  make  the  examination  tiiorough.  In  injuries  of  a  serious  nature 
the  clothing  should  be  removed  by  cutting  or  tearing  the  scams, 
a.s  othcrwi.se  unneces.sary  pain  is  inflicted  and  additional  injuries 
may  be  produced.  Boots  and  shoes  are  removed  in  the  same 
manner.      In    fractures   of  the   spine  and  pelvis,  with  paralysis   or 


368 


FRACTURES. 


injury  of  the  bladder  or  urethra,  a  water  or  air  bed  should  be 
secured  at  once,  to  protect  the  patient  against  bed-sores.  In  frac- 
tures of  the  lower  extremity  requiring  prolonged  rest  in  bed  a 
narrow  bed  with  an  even  hair  mattress  on  a  solid  level  support  is  a 
very  important  requirement  to  successful  treatment  by  continuous 
extension  combined  with  fixation.  A  handle  attached  to  a  rope 
carried  over  a  pulley  fastened  in  the  ceiling  over  the  bed  is  a  great 
convenience  to  the  patient  in  changing  his  position.  Of  all  the 
different  kinds  of  invalid  beds,  Hunger's  gives  the  best  satisfaction. 
The  position  of  the  patient  can  be  changed,  without  disturbing  him, 
by  a  very  simple  contrivance.  It  will  prove  of  the  greatest  benefit 
in  the  treatment  of  fractures  of  the  spine  and  neck  of  the  femur. 
If  the  fracture  of  the  leg  or  thigh  is  to  be  treated  by  extension, 
a  box  covered  with  a  blanket  is  placed  at  the  foot  of  the  bed, 
against  which  the  patient  can  rest  the  foot  of  the  opposite  limb  to 


Fig.  216. — Complete  permanent  dressing  for  fracture  of  the  shaft  of  the  femur. 


prevent  the  body  from  sliding  in  that  direction.  In  all  cases  of 
fracture  of  the  lower  exti^emity  requiring  extension  the  foot  of  the 
bed  should  be  raised  one  foot  or  more,  for  the  purpose  of  utilizing 
the  weight  of  the  body  for  counterextension.  During  the  time 
the  preparations  are  being  made  for  the  dressing  of  the  fracture 
the  physician  makes  the  final  careful  examination,  which  in  doubtful 
complicated  cases  may  require  the  use  of  a  general  anesthetic. 

Reposition  of  the  Fracture. — A  diagnosis  made  and  everything 
being  ready  for  the  dressing,  the  next  duty  of  the  physician  is  to 
reduce  the  fracture.  Reposition  or  reduction  of  a  fracture  signifies 
the  bringing  of  the  fragments,  by  manual  force  and  other  expedi- 
ents, into  the  same  relative  position,  or  as  nearly  so  as  possible, 
that  they  occupied  before  the  injury  occurred.  A  successful  reduc- 
tion has  in  view  the  correction  of  all  deformities,  and  if  this  is  accom- 


REPOSITION    OF    THE    FRACTURE.  369 

plished  to  perfection,  the  normal  length  and  position  of  the  limb  are 
restored.  So  ideal  a  reduction  is  the  exception  ;  partial,  although 
satisfactory,  reduction,  the  rule.  In  oblique  fractures  the  shortening 
may  be  overcome  completely  by  manual  extension,  but  as  soon  as 
the  foot  or  hand  is  released  and  splints  are  relied  upon  in  maintain- 
ing the  position  of  the  limb,  more  or  less  shortening  always  occurs 
as  the  result  of  muscular  contraction.  In  lateral  displacement  it  is 
ver)^  difficult  indeed  to  secure  perfect  contact  between  the  fractured 
surfaces  throughout.  In  rotary  displacement  the  deformity  is 
remedied  without  any  difficulty,  but  a  slight  deviation  may  occur 
before  the  fixation  dressing  is  applied  and  later.  One  rule  that 
should  be  invariably  followed  in  making  the  reposition  is  to  place  the 
shaft  of  the  broken  bone  in  a  position  that  zvill  relax  the  strongest 
muscles.  For  instance,  in  fractures  of  the  humerus  the  arm  should 
be  slightly  abducted  and  the  forearm  flexed,  so  as  to  relax  the  del- 
toid and  biceps  muscles  ;  in  fractures  of  both  bones  of  the  leg  the 
knee-joint  should  be  flexed  ;  in  fractures  of  the  femur  below  the 
trochanters  the  thigh  should  be  flexed  ;  in  fractures  of  the  lower  end 
of  the  femur  much  good  often  is  gained  by  flexing  the  thigh  and 
the  leg.  The  effect  of  relaxing  opposing  muscles  is  best  seen  in 
reducing  a  fracture  of  the  clavicle  with  marked  displacement. 

Besides  extension  and  counterextension,  so  necessary  in  cor- 
recting the  shortening,  digital  or  manual  compression  over  one 
fragment  or  both,  in  opposite  directions,  serves  a  useful  purpose  in 
correcting  angular  and  lateral  displacements.  Pulleys  and  other 
mechanical  contrivances  as  substitutes  for  manual  force  in  the 
reduction  of  fractures  have  become  obsolete  in  the  practice  of 
modern  surgery.  Manual  force,  aided,  if  necessary,  by  a  general 
anesthetic,  will,  under  all  circumstances,  serve  as  an  efficient  mechan- 
ical power  to  correct  the  displacements  as  far  as  is  deemed  safe  and 
prudent.  In  exceptional  cases  one  or  two  assistants  can  furnish  the 
required  traction  force,  while  the  physician  aids  the  reduction  by 
making  pressure  over  the  fragments  where  it  is  needed. 

Exte7tsion  is  most  efficient  when  made  near  the  seat  of  fracture. 
In  fractures  of  the  arm  it  is  made  by  grasping  the  condyles  of  the 
humerus  with  the  arm  flexed,  while  counterextension  is  made  in 
the  axilla.  Elongation  of  the  contracted  powerful  muscles  of  the 
thigh  is  effected,  with  the  least  expenditure  of  force,  by  making 
traction  upon  the  condyles  of  the  femur,  with  the  leg  half-way 
between  flexion  and  extension,  with  perineal  counterextension.  In 
some  fractures  pressure  alone  will  effect  reduction,  as  in  fractures 
of  the  ribs,  scapula,  and  other  flat  bones.  In  grcenstick  fractures 
extension  and  pressure  over  the  convex  side  of  the  angle  will  cor- 
rect the  deformity.  In  Colles'  fracture  extension  of  the  hand  and 
pressure  against  the  dorsal  side  of  the  lower  fragment  are  relied 
upon  in  correcting  the  angular  deformity,  and  ulnar  flexion  of  the 
hand  and  pressure  against  the  lower  end  of  the  ulna  in  reducing 
the  ulnar  subluxation.  In  fractures  of  the  patella  and  olecranon 
24 


370 


FRACTURES. 


the  reduction  consists  in  relaxing  the  muscles  that  have  caused  the 
diastasis,  and  in  pressing  the  fragments  together.  In  fractures  of 
the  spine  forcible  attempts  at  reduction  are  contraindicated,  as  the 
attempt  might  cause  visceral  injury  of  the  cord  by  the  moving 
fragments.  In  fractures  of  the  skull  with  marked  depression,  with 
and  without  brain  symptoms,  reduction  is  made  by  elevation  of  the 
fragments  by  operative  interference. 

-  The  success  of  an  attempt  at  reduction  is  estimated  by  the 
degree  of  disappearance  of  the  displacement.  In  some  cases  the 
reduction  is  announced  by  crepitation  ;  in  others  the  reduction 
may  be  perfect,  or  nearly  so,  without  such  indication.  If  shorten- 
ing is  the  principal  displacement  to  overcome,  measurements  should 
be  made  from  time  to  time  to  ascertain  when  the  limit  of  extension 
as  a  reducing  force  has  been  reached.  As  soon  as  the  shortening 
is  corrected,  coaptation  by  pressure  completes  the  reduction,  as 
rotary  displacement  should  always  be  corrected  before  extension  is 
commenced.  It  is  needless  to  say  that  if  it  is  the  intention  to 
treat  the  fracture  by  continuous  extension,  the  surface  of  the  limb 
should  be  thoroughly  prepared  by  shaving  and  scrubbing  with  hot 
water  and  soap,  followed  by  washing  with  alcohol  and  the  applica- 
tion of  strips  of  adhesive  plaster  before  reposition  is  made. 

Reduction  is  often  made  with  very  little  effort ;  at  times  it  is 
very  difficult,  and  at  others  impossible.  Fractures  of  the  patella, 
olecranon  process,  coracoid  process  of  the  ulna  and  scapula,  and 
the  posterior  process  of  the  os  calcis  can  seldom  be  brought  in 
accurate  coaptation,  and  if  so,  the  moment  the  fingers  that  coap- 
tated  the  fragments  are  removed,  more  or  less  separation  of  the 
fractured  surfaces  at  once  occurs  from  muscular  contraction.  In 
intracapsular  fractures  the  inaccessibility  of  the  proximal  fragment 
to  direct  manipulation  interferes  seriously  with  securing  accurate 
coaptation  of  the  fragments.  Inaccessibility  of  the  fragments  in 
fractures  of  the  sternum,  ribs,  vertebrae,  and  pelvis  is  a  formidable 
obstacle  to  complete  reduction.  Interposition  of  the  soft  tissues 
between  the  fragments  often  proves  an  insurmountable  barrier  to 
complete  reduction.  Extension  and  rotation  are  not  always  efficient 
in  removing  the  obstacle  to  reduction.  Pressure,  rubbing,  and  even 
a  resort  to  the  use  of  the  tenotome  are  not  always  effective  in  re- 
moving the  interposed  soft  tissues,  and  often  pseudarthrosis  can  be 
prevented  later  only  by  an  open  operation. 

Perforation  of  the  soft  tissues,  including  sometimes  the  skin, 
by  a  sharp  fragment  presents  another  difficulty  in  the  way  of  a 
ready  reduction.  Extension,  rotation,  and  forcing,  under  local 
pressure,  the  skin  and  other  soft  tissues,  will  fail  in  many  cases  to 
liberate  the  fragment.  It  is  in  such  cases,  too,  that  interposition 
of  soft  tissues  between  the  fragments  is  very  likely  to  occur  should 
the  manipulations  secure  reduction  of  the  perforating  bone.  In 
difficult  cases  it  is,  therefore,  justifiable  to  cut  down  upon  the  frag- 
ment, under  strict  aseptic  precautions,  with  the  intention  of  liberat- 


IMMOBILIZATION    OF    FRACTURE.  37 1 

ing  it  and  of  securing  accurate  coaptation  of  the  fractured  ends.  In 
impacted  fractures  the  physician  must  decide  what  course  to 
pursue.  In  impacted  fractures  of  the  neck  of  the  femur  and 
humerus  no  attempt  should  be  made  to  correct  the  malposition,  as 
the  impaction,  if  maintained,  furnishes  the  best  possible  condition 
for  union  by  bony  callus,  together  with  the  best  prospects  for  a 
useful  limb.  Extra-articular  impacted  fractures  with  considerable 
deformity  must  be  treated  by  loosening  the  impaction  and  by 
bringing  the  fragments  into  proper  position.  This  is  more  espe- 
cially the  case  in  Colles'  fracture  of  the  lower  end  of  the  radius, 
which  is  so  often  found  impacted  and  which,  if  the  deformity  is  not 
corrected,  x'ields  bad  functional  results. 

In  crushing  injuries  of  the  short,  bones,  such  as  the  vertebrae, 
the  deformity  is  not  improved  by  any  attempts  at  reduction,  owing 
to  the  destruction  of  tissue  by  the  compressing  force  that  produced 
the  fracture. 

Interlocking  fractures  often  present  a  decided  obstacle  to  reduc- 
tion, which,  if  it  can  not  be  accomplished  by  extension,  careful 
flexion,  extension  and  rotary  movements,  is  only  effected,  if  per- 
sisted in,  by  breaking  off  some  of  the  denticulated  projection  that 
locks  the  fracture. 

Extensive  comminution  of  the  bone  offers  no  obstacle  to  reduc- 
tion, but  as  soon  as  manual  traction  is  suspended,  some  of  the  frag- 
ments become  displaced,  and  more  or  less  shortening  occurs  in  spite 
of  a  perfectly  fitting  mechanical  support. 

Fractures  complicated  by  dislocation  present  unusual  difficul- 
ties in  bringing  the  fractured  surfaces  in  accurate  contact  and  in 
maintaining  accurate  coaptation  by  any  kind  of  fixation  dressing. 
Cross-position  of  fragments  is  very  difficult  to  correct,  and  if  exten- 
sion, gentle  rotary  movements,  and  direct  pressure  fail,  they  are 
allowed  to  remain  unless,  by  pressure,  they  should  cause  serious 
s\'mptoms,  when  they  are  removed  by  making  an  open  incision. 

Immobilization  of  Fracture. — Reduction  of  a  fracture  is  fol- 
lowed by  substituting  for  the  hands  a  dressing  that  will  hold  the 
fragments  in  place  and  immobilize  them.  Perfect  retention  and 
immobilization  of  the  fragments  after  complete  reduction  constitute 
the  ideal  mechanical  treatment  and,  if  accomplished,  yield  the  best 
functional  results.  Like  reduction,  perfect  retention  is  possible  only 
in  a  limited  number  of  cases  in  which  the  fractured  surfaces  are 
such  as  to  render  material  aid  to  the  mechanical  treatment  in 
antagonizing  the  displacing  forces.  Perfect  retention  under  any 
kind  of  treatment  is  almost  an  impossibility  in  oblique  fractures  of 
the  shaft  of  the  humerus  and  femur,  and  more  or  less  longitudinal, 
lateral,  or  rotary  displacement  is  inevitable,  but  under  proper  treat- 
ment the  (iis[)Iacements  are  usually  so  slight  as  not  to  interfere  with 
a  perfect  functional  result.  In  transverse  fractures  retention  and 
fixatif)n  of  the  fragments  after  a  satisfactory  reduction  present  no 
unusual  mechanical  difficulties,  as  the  natural  support  between  tiie 


3/2  FRACTURES. 

broad  fractured  surfaces  effectually  guards  against  shortening  to 
any  extent,  and  lateral  and  axial  displacements  can  be  prevented  by 
very  simple  mechanical  treatment. 

Position. — All  retention  dressings  must  be  applied  with  due 
regard  for  a  correct  position  of  the  fractured  limb.  In  selecting  a 
proper  position  of  the  limb  we  must  study  the  effect  of  muscular 
contraction  as  a  displacing  force.      This  is  done  during  the  reduc- 


Fig.  217. — Fracture  of  the  femur  about  three  inches  below  the  trochanter  minor,  with 
tilting  of  the  upper  fragment  forward  and  outward. 

tion  of  the  fracture.  In  replacing  the  fragments  muscular  resis- 
tance will  assert  itself,  and  the  effect  of  such  action  as  a  displacing 
force,  during  and  after  reduction,  must  be  carefully  studied.  The 
fractured  limb  must  be  placed  in  a  position  that  will  relax  the  prin- 
cipal muscles  that  tend  to  reproduce  the  displacements  after  reduc- 
tion-. All  positions  and  dressings  that  interfere  with  this  rule  are 
harmful  and  must  be  scrupidoiisly  ai'oided. 

Much  harm  has  been  done  by  ignoring  position  as  one  of  the 


POSITION. 


373 


most  important  elements  of  tlie  successful  treatment  of  fractures. 
A  few  instances  will  suffice  to.  corroborate  the  force  and  correct- 
ness of  this  statement.  I  have  seen  a  number  of  cases  of  fracture 
of  the  femur,  from  one  to  several  inches  below  the  trochanter 
minor,  treated  b}'  extension  and  fixation  with  the  thigh  in  a  straight 
position,  with  the  inevitable  results — vicious  union,  great  angular- 
ity, and  marked  shortening.  Extension  and  fixation  in  such  cases 
have  no  control  over  the  upper  fragment,  which  is  tilted  forward 
and  outward  by  contraction  of  the  iliopsoas  and  gluteal  muscles. 
The  lower  fragment,  over  which  we  have  control,  must  be  made 
to  correspond  with  the  axis  of  the  upper,  to  prevent  angular 
deformity  and  to  secure  the  full  benefit  of  extension.  Fractures  of 
the  upper  cud  of  the  femur  must  he  treated  by  extension  on  tJie  flexed 
thigh  in  the  direction  of  the  upper  fragment,  with  the  limb  placed 


Fig.  218. — Dressing  of  fracture  of  the  femur  in  the  upper  third  with  extension  upon 
inclined  plane  (Agnew). 


Fig.    219. — .^gnew's    splint  for    fractured 
patella. 


Fig.  220. — Agnew' s  splint  applied. 


Upon  a  double  inclined  plane,  at  an  angle  that  will  bring  the  axis  of 
the  lower  in  line  with  the  axis  of  tlie  upper  fragment.  In  fractures 
of  the  patella  treated  without  direct  fixation,  the  diastasis  between 
the  fragments  can  only  be  removed  by  relaxing  the  quadriceps 
extensor  femoris  muscle,  which  has  caused  it,  and  this  can  only  be 
done  by  extending  and  elevating  the  limb,  to  an  angle  of  at  least  45 
degrees  before  local  external  means  of  retention  gains  an\^  control 
whatever  over  the  ujjper  fragment.  Agnew's  splint  with  a  foot-board 
attached  constitutes  the  very  best  dressing  for  fracture  of  the  patella. 
In  fractures  of  the  olecranon  process  we  must  rely  on  relaxing 
the  triceps  muscle  in  bringing  the  fragments  together,  and  are 
obliged  to  apply  the  fixation  dres.sing  with  the  forearm  in  the 
extended  position,  and  to  support  the  upper  fragment  in  position 
with  stri[)s  of  adhesive  i)lastcr  in  the  same  manner  as  in  fractin'c  of 


374 


FRACTURES. 


Fig.   221. — Dressing  for   fracture  of  both 
bones  of  the  forearm. 


the  patella.  In  fractures  of  both  bones  of  the  forearm  the  dress- 
ing is  applied  with  the  forearm  flexed,  and  in  a  position  half-way 
between  pronation  and  supination,  to  antagonize  muscle  action  and 

guard  against  the  fragments  en- 
croaching upon  the  interosseous 
space. 

In  fractures  of  the  posterior 
process  of  the  os  calcis  the  foot 
and  knee  are  flexed  and  main- 
tained in  this  position,  to  ap- 
proximate the  points  of  origin  and  insertion  of  the  gastrocnemius 
and  soleus  muscles.  The  importance  of  muscle  relaxation  was 
recognized  years  ago,  by  Mr.  Pott,  as  an  important  aid  in  securing 
retention  in  fractures  of  the  leg.  He  relied  largely  on  flexion  of 
the  knee-joint  and  lateral  position  of  the  body  in  bringing  and 
holding  the  fragments 
in  contact. 

Strict  attention  to 
muscle  relaxation  con- 
stitutes the  main  ob- 
ject of  all  dressings  for 
fracture  of  the  clavicle. 
Limitation  of  the  res- 
piratory movements  by 
circular  compression 
of  the  chest  is  the  prin- 
cipal treatment  in  frac- 
tures of  the  ribs.  Pro- 
visional dressings  are 
often  employed  in  ob- 
taining the  full  benefits 
of,  and  in  maintaining 
for  the  requisite  length 
of  time,  the  most  fav- 
orable position  of  the 
fractured  limb.  In 
fractures  of  the  ster- 
num, pelvis,  and  in 
many  fractures  of  the 
vertebrae  retention  is 
secured  almost  exclu- 
sively by  position.  The 
patient  is  placed  in  the 

dorsal  recumbent  position,  on  a  level  mattress  or  a  water  or  air  bed, 
and  cushions  or  compresses  are  utilized  where  local  pressure  will 
afford  comfort  or  add  to  the  fixation  of  fragments.  In  fractures  of 
the  extremities  with  great  swelling  and,  perhaps,  extensive  blistering 
of  the  skin,  position  and  a  provisional  dressing  are  resorted  to  after 


Fig.  222. — Flexion  and  lateral  position  (after  Pott). 


TEMPORARY    DRESSING. 


375 


reduction  has  been  made,  to  maintain  coaptation  and  retention,  as 
well  as  can  be  done  under  the  circumstances,  until  the  swelling 
subsides,  when  the  fragments  are  again  carefully  adjusted  before  a 
permanent  dressing  is  applied.  A  permanent  dressing  with  an 
unyielding  circular  support  has  often  resulted  disastrously  in  such 
cases.  If  the  swelling  increases  in  size,  obstructed  venous  circu- 
lation and,  perhaps,  complete  arrest  of  the  circulation  have  resulted 


Fig.  223. — Sayre's  dressing:  a.  First  strip  ;  b,  second  strip,  front  and  back  views. 

in  gangrene  ;  and  if  the  swelling  diminishes  in  size,  the  mechanical 
support  no  longer  maintains  retention,  and  its  presence  often  does 
more  harm  than  good. 

A  provisional  or  temporary  dressing  is  one  that  does  not  aim 
at  perfect  retention  or  fixation,  owing  to  the  existence  of  a  wound, 
great  swelling,  or  other  contraindications  to  a  permanent  dressing. 
It  is  employed,  in  connection  with  position,  to  effect  relative  fixation 


Fig.  224. — Mantle  splint  (von  Esmarch). 


compatible  with  the  condition  of  the  injured  part  or  limb,  and  is 
continued  until  the  local  or  general  conditions  warrant  accurate 
adjustment  and  permanent  fixation.  We  expect,  from  a  provisional 
dressing,  that  it  will,  under  no  circumstances,  compromise  the  circu- 
lation or  vitality  of  the  tissues  ;  that  it  will  be  a  source  of  comfort 
to  the  patient,  and,  combined  with  position,  will  secure  for  the  scat 
of  fracture  at  least  a  relative,  if  not  a  ])erfect,  condition  of  rest. 


37.6 


FRACTURES. 


Cushions  containing  chaff,  straw,  hair,  bran,  or  sand  answer  an 
excellent  purpose  in  immobilizing,  with  or  without  splints,  either 
the  upper  or  the  lower  extremity.  If  splints  are  used,  the  contents 
of  the  cushion  should  be  elastic, — hair,  cotton,  wool,  etc., — to 
guard  against  harmful  compression.  Sand-bags  molded  to  the 
surface  of  the  limb  are  often  relied  upon  as  a  provisional  dressing. 
Dry  earth,   bran,   and    flour   can  be  used  for  the  same  purpose. 


Fig.  225. — Straw  splints  (von  Esmarch). 

A  cushion  divided  into  two  sections  by  a  seam  in  the  center  is  a 
very  useful  and  favorite  form  of  dressing  by  this  method.  Stro- 
meyer's  triangular  cushion  for  the  axilla  and  chest  bandage  makes 
an  excellent  provisional  dressing  for  fractures  of  the  humerus.  A 
large  triangular  pillow,  on  the  plan  of  a  double  inclined  plane, 
serves  well  in  fractures  of  the  leg  or  thigh  accompanied  by  exten- 
sive swelling. 

The  fracture  box  is   seldom  used  in  the  practice  of  modern. 


Fig.  226. — Stromeyer's  arm 
cushion  (Bruns). 


227. — Dumreicher's  wedge  cushion  for  the 
lower  extremity  (Dumreicher). 


surgery.  Many  forms  of  this  apparatus  have  been  in  use,  none 
of  these,  however,  presenting  any  advantage  over  the  original  in- 
vention of  Petit.  The  fracture  box  has  had  its  day,  and  as  there 
is  no  reason  to  justify  a  demand  for  its  reinstatement,  few  physicians 
would  feel  inclined  to  have  one  made  in  an  emergency. 

The  double  inclined  plane  can  be  used  advantageously  as  a 
substitute  for  the  fracture  box,  and  as  this  apparatus  can  be  made 


SUSPENSION    SPLINTS. 


377 


from  a  piece  of  board,  two  hinges,  and  with  the  simplest  tools,  it 

can  be  extemporized  in  almost  any  place  in  less  than  half  an  hour. 

The  simplest  double  inclined  plane  consists  of  two  pieces  of  board 

perforated    at    a 

number   of  points,  iii!;i)llllik 

and   connected    by 

two   hinges,  or,  in 

the    absence     of 

these,  two  strips  of 

leather  will  answer, 

the    incHne    being 

regulated  with  two 

cords,  one  on  each 

side. 

Esmarch's  double 
inclined  plane,  with  a  place  cut  out  for  the  heel  and  a  number 
of  erect  sticks  on  each  side,  is  a  somewhat  more  complicated  appa- 
ratus, but  has  this  great  advantage,  that  the  sides  of  the  limb  can 
be  supported  by  pillows  placed  between  it  and  the  sticks,  giving 
the  limb  a  wider  surface  for  support.  The  cut-out  space  serves  to 
protect  the  heel  against  decubitus.  With  a  bandage  wound  around 
the  foot  behind  the  base  of  the  toes,  and  tied  to  one  of  the  sticks 
on  each  side,  the  foot  can  be  supported  and  held  in  proper  position. 

The  double  inclined  plane  will  always  remain  as  a  valuable 
provisional  dressing  in  fractures  of  the  thigh  and  leg  not  adapted 
for  a  permanent  fixation   dressing,   and  in  fractures   of  the   upper 


Fig.  228. — Petit's  fracture  box  (Bruns). 


Fig.  229. — Esmarch's  double  inclined  plane. 

end  of  the  femur,  combined  with  extension  and  continued  as  a 
permanent  dressing,  it  will  .secure  the  best  results. 

Suspension  Splints. — In  fractures  of  the  leg  and  in  some  frac- 
tures of  the  thigh  suspension  is  one  of  the  important  mechanical 
resources  in  immobilizing  the  fragments  and  securing  rest  for  the 
injured  limb.  In  fixed  dressings,  with  and  without  extension,  every 
movement  of  the  body  may  disturb  the  fragments  in  the  limb  fixed 
by  the  .stationary  dressing.  If  the  immobilized  limb  is  suspended, 
it  moves  with  the  body,  and  disturbance  of  the  fragments  by  the 
patient  himself  is  less  likely  to  occur. 

The  simplest  susjjcnsion  apparatus  and  one  that,  besides  being 


378 


FRACTURES. 


useful,  can  be  extemporized  anywhere  and  in  a  short  time,  consists 
of  a  square  piece  of  canvas  or  any  other  strong  cloth,  and  two 
sticks  the  length  of  the  leg,  which  are  sewed  into  two  correspond- 
ing margins  of  the  cloth.  With  four  cords  tied  to  the  ends  of  the 
sticks  and  fastened  to  a  staple  secured  in  the  ceiling  above  the  bed 
the  canvas,  with  the  leg  resting  on  it,  is  swung  at  the  desired  height. 
The  patient  is  the  best  judge  in  determining  the  level  at  which  sus- 
pension is  made,  as  the  limb  must  be  placed  in  a  position  affording 
the  greatest  degree  of  comfort. 

The  suspension  splints  that  have  found  most  favor  and  given 
the  best  satisfaction  in  this  country  are  those  designed  by  Mclntyre, 
N.  R.  Smith,  and  Hodgen.      Smith's  anterior  splint  has  had  a  very 


Fig.  230. — R.  N.  Smith's  anterior  suspension  splint. 


Fig.  231. — Smith's  suspension  splint  applied. 


extended  and  satisfactory  trial,  and  can  be  extemporized  from  a 
piece  of  telegraph  wire  and  adapted  to  each  individual  case. 
The  splint  is  applied  and  suspension  made  as  shown  in  figure  231. 
Hodgen's  splint  is  made  of  the  same  material  and  is  applied  in  a 
very  similar  manner,  but  suspension  is  combined  with  extension, 
giving  it  particular  usefulness  in  the  treatment  of  fractures  of  the 
femur  requiring  extension. 

Ready =made  Splints. — The  sale  of  manufactured  splints  for 
the  treatment  of  fractures  has  come  nearly  to  a  standstill,  for  sur- 
geons have  found,  by  sad  experience,  that  splints,  like  shoes,  in 
order  to  be  tolerated  or  worn  with  comfort  and  ease  must  be  made 
to  fit  each  individual  case.      It  would  be  time  and  labor  lost  should 


READY-MADE    SPLINTS. 


379 


an  attempt  be  made  here  to  describe  the  numerous  splints  that  have 
been  devised  for  special  fractures.  Many  of  these  splints  are 
evidences  of  deep  study  and  careful  observation,  and  when  made 
for  the  case  on  which  they  were  first  used,  may  have  answered  the 
local  indications,  but  when  used  on  a  second  case,  their  unfitness 
must  have  become  apparent.  The  defects  in  the  surface  of  the 
splint  were  undoubtedly  corrected  to  some  extent  by  filling  in 
empty  spaces  with  pads  and  by  making  ridges  that  were  calculated 
to  fit  into  anatomic  depressions  more  or  less  prominent  by  again 
resorting  to  padding.  Ready-made  splints  might  possibly  fit  the 
same  limb  of  two  individuals  of  exactly  the  same  size  and  weight 
in  a  normal  condition,  but  the  same  splint  certainly  could  not  be 
expected  to  fit  the  same  limbs  when  fractured,  as  the  location  of 


Fig.  232. — Hodgen's  suspension  splint. 


the  fracture  and  the  degree  of  displacement  and  swelling  would  not 
be  exactly  alike  in  both  instances.  Splints,  to  fit,  must  be  made 
for  each  individual  case,  and  the  physician  who  has  not  the 
mechanical  ingenuity  to  make  his  own  splints  should  not  undertake 
the  treatment  of  fractures.  The  splint  should  not  be  made  until 
after  the  examination  has  been  completed,  as  the  location  and 
nature  of  the  fracture  and  the  degree  of  swelling  must  guide  the 
physician  in  making  the  splints. 

There  are  two  ready-made  splints  that  every  physician  should 
keep  in  his  office  and  that  he  should  make  himself  They  are 
excellent  provisional  splints  for  different  kinds  of  fractures,  and  the 
best  permanent  thigh  .sjjlints  in  the  treatment  of  fractures  of  the 


38o 


FRACTURES. 


femur  by  extension  and  fixation.  Gooch's  splint  is  made  by  pasting 
a  thin  pine  board,  not  over  one-fourth  of  an  inch  in  thickness,  two 
feet  in  length,  and  of  convenient  width  (6  by  8  inches),  upon  linen  or 
leather  with   flour    paste  or  glue,    and,    after   drying,    cutting  the 


in 


Fig.  233. — Gooch's  splint. 

board  partly  through  into  parallel  strips  about  three-fourths  of  an 
inch  in  width.  When  used,  the  splint  is  cut  the  proper  length  and 
width  and  the  strips  are  separated  by  breaking  the  remainder  of  the 
wood.  Esmarch's  splint  answers  the  same  purpose,  but  is  made  in 
a  somewhat  different  manner.      The  wood,  i  V^  mm.  in  thickness,  is 


Von  Esmarch's  splint. 


first  cut  into  strips  that  are  placed  between  two  layers  of  cotton 
cloth,  which  is  then  saturated  with  silicate  of  soda  solution,  which 
holds  the  strips  in  place.  The  cloth  between  the  strips  can  be  cut 
with  scissors,  and  splints  of  the  required  length  and  width  obtained. 
Schnyder  makes  such  splint  material  by  sewing  the  strips  of  wood 


READV-MADE    SPLINTS.  38  I 

between  two  layers  of  linen  or  cotton  cloth,  leaving  a  narrow  space 
between  them.  Any  of  these  splints,  cut  into  proper  shape,  well 
padded,  and  carefully  applied,  is  very  serviceable  in  emergency 
work  as  well  as  in  hospital  practice,  and  it  is  a  source  of  regret 
that  their  use  has  not  become  more  general.  All  other  splints 
should  be  made  at  the  bedside  of  the  patient.  Thin  pine  board,  a 
jack-knife,  absorbent  cotton,  and  a  gauze  roller  will  furnish  the 
material  requisite  for  any  provisional  splint.  The  spHnt  must,  in  all 
cases,  correspond  with  the  width  of  the  limb  and  the  length  that  is 
to  be  immobilized.  No  mistakes  must  be  made  in  these  respects,  as 
a  narrow  splint  will  endanger  the  circulation  of  the  limb,  and  in 
case  it  is  used  for  the  forearm  or  the  leg,  it  would  determine 
encroachment  upon  the  interosseous  space  by  deviating  the  fragments 
in  that  direction.  It  must  be  of  sufficient  length  to  immobilize  the 
fractured  bone,  as  otherwise  it  would  not  effect  the  fixation  required  ; 
if  too  long,  it  would  expose  the  limb  to  unnecessary  sources  of 
unrest. 

The  opposite  limb  should  serve  as  a  model  in  determining  the 
length,  width,  and  outlines  of  the  splint.  Over  bony  prominences 
defects  are  made  in  the  splint — as  for  the  heel  in  posterior  splints 
for  the  leg,  and  for  the  condyles  of  the  humerus  in  lateral  splints 
for  fractures  of  the  arm,  and  for  the  ball  of  the  thumb  in  anterior 
splint  for  fractures  of  the  forearm.  The  padding  of  the  splint 
must  be  done  with  the  utmost  care,  so  that  the  surface  of  the  splint 
will  fit  the  contour  of  the  limb  to  which  it  is  to  be  applied.  The 
best  material  for  the  padding  is  absorbent  cotton,  which  is  suffi- 
ciently elastic  and  molds  itself  to  the  surface  of  the  limb  better 
than  any  other  material  used  for  this  purpose.  At  the  same  time 
it  absorbs  the  moisture  from  the  skin.  If  the  skin  is  abraded  or 
blistered,  it  should  be  dusted  with  borosalicylic  powder  before  the 
spHnt  is  applied. 

Provisional  splints  must  be  supplied  with  a  cushion  of  cotton 
from  two  to  four  inches  in  thickness,  in  order  to  secure  enough 
elasticity  to  allow  for  an  increa.se  of  the  swelling.  The  padding 
must  correspond  with  the  irregular  spaces  between  the  surface  of 
the  limb  and  tiie  plane  of  the  splint.  The  border  of  the  splints  for 
the  forearm  and  leg  must  be  raised  by  adding  to  the  thickness  of 
the  padding  here,  so  that  the  cotton  cushion  on  the  splint  will  be 
concave,  to  supplement  the  convexity  of  the  limb.  This  part  of  the 
construction  of  a  splint  is  very  important,  as  a  flat  splint  will  make 
unequal  pressure,  producing  pain,  decubitus,  and  pressure  atrophy, 
while,  on  the  other  hand,  a  splint  the  surface  of  which  is  supplied 
with  a  cotton  cushion  that  fits  the  surface  of  the  limb  will  make 
what  is  so  desirable,  equable  support — so  essential  in  the  preven- 
tion of  harmful  localized  points  of  pressure  and  so  useful  in  secur- 
ing muscular  rest  and  in  maintaining  uninterrupted  retention. 

Fixation  of  the  cottfMi  j)a(lding  upon  the  surface  of  the  splint 
with  a  gauze  roller  is  another  very  essential  detail  in  finishing  the 


382 


FRACTURES. 


splint,  and  one  that  is  so  frequently  omitted.  If,  as  is  so  often 
done,  the  cotton  is  placed  loosely  between  the  splint  and  the  limb, 
the  padding  will,  in  the  iirst  place,  never  fit,  and  in  the  second 
place  is  sure  to  become  displaced.  Tlie  padding  must  be  a  part  of 
the  splint  itself,  and  to  make  it  so  it  must  be  carefully  fastened  to  the 
surface  of  the  splint  ivith  a  gauze  roller.  A  gauze  roller  is  prefer- 
able to  a  cotton  roller,  as  it  is  thinner,  applies  itself  more  smoothly 
to  the  surface  of  the  splint,  and  as  it  is  hygroscopic  and  aseptic, 
permits  the  moisture  from  the  skin  to  enter  the  cotton  cushion, 
at  the  same  time  constituting  a  part  of  the  aseptic  dressing  upon 
the  wooden  splint,  which,  in  case  the  skin  is  abraded  or  blistered, 
is  a  decided  advantage.  The  roller  is  first  applied  lengthwise  over 
the  splint,  not  too  firmly,  as  in  a   provisional   splint  the  padding 

should  be  elastic.  After  the 
cotton  has  been  fastened  se- 
curely lengthwise  upon  the 
splint,  the  roller  at  one  cor- 
ner is  fixed  with  a  safety-pin 
and  then  wound  around  the 
splint,  somewhat  obliquely, 
the  whole  length  of  it,  so 
that  the  cotton  is  completely 
covered.  The  end  of  the  roller 
bandage  is  then  fastened  with 
a  pin  to  the  posterior  surface 
of  the  splint.  Splints  made 
according  to  these  directions 
will  fit  the  surface  of  the  limb, 
and  when  properly  fastened 
in  position,  will  furnish  the 
necessary  equable  mechanical 
support  and,  moreover,  will 
not  be  likely  to  become  dis- 
placed. 

Provisional  and  permanent 
splints  should  be  fixed  in  position  by  at  least  two  strips  of  adhesive 
plaster,  and  over  them  a  gauze  roller.  The  gauze  roller  is  more 
elastic  than  the  cotton  roller,  and  on  this  account  should  receive 
the  preference  ;  at  the  same  time  it  is  more  porous,  and  permits 
freer  evaporation  of  the  moisture  from  the  surface  of  the  injured 
limb. 

In  all  dressings,  including  all  kinds  of  splints,  the  tips  of  the 
fingers  and  toes  must  remain  exposed,  as  from  their  appearance  the 
surgeon  can  Judge,  from  time  to  time,  the  condition  of  the  peripheral 
circulation,  and  the  degree  of  sensation  ascertained  by  touch  and 
otherwise  affords  an  insight  into  the  condition  of  the  principal  nerve- 
trunks.  In  other  words,  repeated  examinations  of  the  fingers  and 
toes  by  sight  aiid  touch  enable  the  surgeon  to  ascertain,  in  time,  the 


235. — Splint  for  fracture  of  the  humerus. 


REAnV-MADE    SPLINTS. 


383 


Fig.  236.  —  Raoult-Deslongchamp's  zinc 
splint  for  fractures  of  the  leg. 


existence  of  hannfnl  coDipressioti  on  the  part  of  the  dressing,  blood 
extravasation,  inflainniatory  products,  or  displaced  fragments. 

In  fractures  of  the  arm  the  spHnts  should  include  the  shoulder- 
and  elbow-joints  ;  in  fractures  of  the  forearm  they  should  reach 
from  the  bend  of  the  elbow  to  the  base  of  the  fingers  ;  in  fractures 
of  the  femur,  from  the  pelvis  to  the  sole  of  the  foot ;  in  fractures  of 
the  leg,  from  the  knee-joint  to  the  base  of  the  toes.  A  foot-board 
attached  to  one  of  the  splints  is 
an  important  part  of  the  fixation 
dressing  in  all  fractures  of  the 
leg,  as  it  furnishes  a  support  to 
the  foot,  preventing  flexion,  an 
almost  constant  remote  condition 
and  one  so  often  difficult  to  cor- 
rect after  the  fracture  has  united. 
Pasteboard  splints  should  be 
used  only  in  fractures  of  the 
fingers,  as  their  resisting  power 
can  not  be  relied  upon  in  dress- 
ing a  fracture  of  any  of  the  long  bones  with  marked  tendency  to 
displacement.  In  children  the  subjects  of  greenstick  fracture  they 
are  often  used  as  permanent  splints,  but  it  requires  a  long  time  for 
the  pasteboard  to  become  dry  and  resistant,  and  during  this  time, 
unless  special  precautions  are  taken,  the  deformity  may  reappear. 
If  a  plastic  splint  is  required,  plaster-of-Paris  is  a  much  more  re- 
liable material  than  pasteboard  or  leather.  The  same  objections 
apply  to  leather  splints. 

Tin  splints  have  the  advantage  over  wooden  splints  in  that 
the  material  can  be  molded  to  the  surface  of  the  limb,  but  it  is  ex- 
tremely difficult  to  make  it  fit  the  irregular  surface  of  the  limb,  the 
defects  having  to  be  corrected  by  padding.  Sheets  of  zinc  (No.  8, 
0.4  mm.  in  thickness)  can  be  cut  with  ordinary  scissors  and  molded 
into  proper  shape  much  more  easily  and  accurately  than  ordinary 
tin.   Zinc  splints  and,  what  resembles  them  closely  in  practical  utility, 

wire  splints  rec- 
ommend them- 
selves more  es- 
pecially as  pro- 
visional splints 
in  military  and 
emergency  sur- 
gery. Of  all 
metallic  splints, 
the  wire  splint 
is  the  safest  and  most  useful,  as  it  can  be  molded  into  proper 
shape  with  the  hands,  and  the  splint  permits  free  evaporation  of 
the  perspiration.  .Stn^ng  wire  gauze,  which  can  be  cut  with  a 
strf>ng   pair  of  scissors,   is   the   best   material.      The  edges  of  the 


Fig.  237.  —  Raoult-Deslongchamp's  splint  ajjplied. 


384 


FRACTURES. 


splint,  after  it  has  been  cut,  should  be  bent  over  or  covered  with 
a  hemming  of  cloth,  to  protect  the  skin  against  irritation  from  the 
cut  ends  of  the  wires. 

Plastic  splints,  immovable  and  removable,  have,  at  the  present 

time,  a  wide  range 
of  application  in 
the  treatment  of 
fractures  of  the  ex- 
tremities. The  di- 
rections for  mak- 
ing these  splints, 
the  indications  for 
their  use,  and  the 
cautions  to  be  ob- 
served in  their  ap- 
plication will  be 
given  in  detail  in 
the  chapter  on 
Compound  Frac- 
tures. Circular 
plastic  splints  are  seldom  used  as  a  primary  fixation  dressing, 
except  in  cases  in  which  there  is  nothing  to  fear  from  circular 
compression  and  when  there  is  little  or  no  tendency  to  longi- 
tudinal displacement.  The  immovable  plastic  splints  are  the  ideal 
splints  after  the  primary  swelling  has  subsided  and  union  is  firm 
enough  to  prevent  shortening.  Plastic  splints,  like  any  other 
splints,  are  frequently  employed  as  a  first  fixation  dressing,  as  when 
properly  made  and  applied,  there  is  no  danger  from  circular  and 


Fig.  238.^Wire  splints  connected  with  cords  (Bruns) 


Fig.  239. — Immovable  circular  plaster-of- Paris  splint  applied  for  fracture  of  the  leg 

(von  Esmarch). 


localized  harmful  pressure,  as  it  can  be  molded  accurately  to  the 
surface  of  the  limb.  When  used  as  a  provisional  splint,  it  must  be 
well  padded  with  cotton  or  some  other  elastic  material,  to  guard 
against  harmful  pressure  caused  by  an  increase  of  swelling  at  the 
seat  of  fracture.  The  materials  in  most  common  use  for  plastic 
splints  are  plaster-of-Paris,  starch,  pasteboard,  leather,  felt,  gutta- 
percha, glue,  dextrin,  and  silicate  of  soda.  The  material  which 
can  be  molded  most  readily  and  accurately  at  the  surface  of  the 
limb   and  which  will,  in  the   shortest   time,  pass  from  the  plastic 


PLASTIC    SPLINTS. 


385 


into  the  permanent  firm  state  is  the  one  that  will  adapt  itself  best 
to  the  use  of  the  surgeon.  This  material  is  plaster-of-Paris,  as  it 
is  cheap,  readily  obtainable,  easily  molded,  and  sets  in  the  shortest 
period  of  time.  Pasteboard,  leather,  and  felt  are  sometimes  useful 
as  provisional,  but  are  not  strong-  enough  as  permanent,  splints 
when  there  is  any  considerable  tendency  to  displacement.  Gutta- 
percha is  expensive  and  can  not  be  molded  with  the  same  ease  and 
accuracy  as  plaster-of-Paris.  Glue,  starch,  dextrin,  and  silicate  of 
soda  are  very  plastic  materials,  but  it  requires  hours  before  the 
material,  by  drying,  becomes  firm  enough  to  serve  the  purpose  of  a 
splint.  Plaster-of-Paris  is  the  material  par  excellence  for  plastic 
splints,  circular  and  lateral,  bracketed  and  fenestrated,  and,  when 
ever  necessary,  it  can  be  strengthened  by  incorporating  in  it  strips 
of  wood,  tin.  or  iron. 

The  plaster  is  used  by  incorporating  it  in  rollers  of  loosely 
meshed  fabric,  such  as  crinolin,  organtin,  or  the  ordinary  cheese- 
cloth. Bandages  thus  prepared  should  be  wrapped  in  waxed  paper 
and  stored  in  air-tight  cases.      If  the  plaster  becomes  impaired  by 


Fig.  240. — Beely's  plaster-of-Paris  hemp  splint  for  fractures  of  the  leg,  with  wire  rings 

for  suspension. 

absorption  of  moisture,  it  may  be  exposed  to  slow^  dry  heat 
until  the  moisture  is  removed.  Salt,  alum,  or  any  other  sub- 
stances that  hasten  the  setting  of  the  plaster  are  harmful,  as  when 
the  pla.ster  sets  more  slowly,  the  splint  can  be  molded  more  satis- 
factorily and  is  stronger  and  more  durable.  The  circular  plaster- 
of-Paris  splint  can  be  made  removable  by  cutting  it  on  one  or  both 
sides,  but  the  fitting  qualities  are  at  once  seriously  impaired,  and  it 
soon  becomes  necessary  to  replace  it  by  a  new  one. 

Beely,  who  has  done  most  excellent  work  in  the  development 
of  removable  plaster  splints,  has  used  hemp  very  extensively  as  a 
framework  for  the  plaster.  The  fibers  of  hemp  (from  thirt}'  to 
fifty  inches  in  length)  should  be  placed  parallel  in  small  biuuilcs,  two 
to  three  inches  in  width  and  half  an  inch  in  thickness,  which  are 
then  twisted  into  a  loose  cord  of  the  thickness  of  the  little  finger. 
A  plaster  cream  is  then  made  by  mixing  equal  parts  of  warm  water 
and  plaster-of-Paris.  The  hemp  cords  are  then  drawn  through  the 
cream  slowly,  so  as  to  saturate  the  meshes  well,  when  they  arc  laid 
over  the   limb  jjarallel  to  each   other  and  close  together,  until  the 

2$ 


386  FRACTURES. 

splint  has  reached  the  desired  size.  The  sphnt  should  be  thickest 
in  the  center.  The  width  of  the  splint  should  correspond  with 
one-third,  never  more  than  one-half,  of  the  circumference  of  the 
limb.  If  fixation  is  to  be  combined  with  suspension,  wire  rings  are 
placed  at  suitable  distances  from  one  another,  in  a  straight  line,  in 
the  center  of  the  sphnt,  by  inserting  them  between  the  layers  of 
the  bundles  of  hemp. 

Inclined  Plane. — The  use  of  the  double  and  single  inclined 
plane  has  been  referred  to  in  connection  with  position  as  an  aid  in 
the  mechanical  treatment  of  fractures.  In  some  fractures  of  the 
thigh  and  leg  the  inclined  plane,  single  or  double,  is  often  com- 
bined with  splint  fixation  and  permanent  extension.  The  inclined 
plane  will  often  accomplish  more  than  extension,  and  when  com- 
bined with  extension,  will  accomplish  what  is  so  necessary  in  the 
treatment  of  very  oblique  fractures,  relaxation  of  muscles  and 
correction  of  longitudinal  and  lateral  displacements. 

Permanent  extension  by  weight  and  pulley  is  one  of  the 
approved  methods  of  treatment  of  oblique  fractures  of  the  femur 
and  both  bones  of  the  leg.  It  is  sanctioned  by  all  authorities,  and 
has  yielded  the  best  results.  Extension  must  ahvays  be  made  m  the 
direction  least  likely  to  excite  musculai^  contraction — that  is,  in  a 
direction  that  will  not  come  in  conflict  zvith  a  position  of  the  limb 
calcidated  to  favor  muscle  relaxation.  In  fractures  of  the  femur 
the  influence  of  position  on  muscle  relaxation  must  be  carefully 
studied  before  deciding  in  what  direction  the  extension  is  to  be 
made.  In  fractures  of  the  upper  and  lower  ends  of  the  bone 
extension  must  often  be  made  with  the  limb  resting  upon  a  double 
or  single  inclined  plane.  Tlie  experience  gained  in  making  the 
rediiction  will  indicate  to  zvhat  extent  position  will  aid  extension. 
My  observations  and  experience  have  satisfied  me  that  position 
of  the  limb  has  not  been  utilized  to  the  extent  it  deserves  to  be 
in  securing  the  full  benefit  of  permanent  extension.  No  strict 
rules  can  be  laid  down  to  guide  the  physician  in  determining  upon 
the  direction  in  which  extension  should  be  made.  This  important 
matter  must  be  studied  in  connection  with  each  individual  case,  as 
the  location  of  the  fi'acture,  the  line  of  fracture,  and  the  degree  of 
muscle  power  are  varying  conditions  that  have  a  direct  bearing  on 
the  position  in  which  the  limb  should  be  placed  most  favorable  to 
extension. 

Elastic  extension  with  the  aid  of  a  special  apparatus  is  some- 
times resorted  to,  but  the  general  practitioner  will  rely  almost 
exclusively  on  the  weight  and  pulley  in  making  permanent  exten- 
sion. This  method  is  employed  occasionally  in  the  treatment  of 
oblique  fractures  of  the  forearm,  but  the  cases  are  very  rare,  indeed, 
in  which  it  becomes  necessary  to  confine  a  patient  with  fracture  of 
the  forearm  to  bed  for  the  purpose  of  securing  the  benefits  of  per- 
manent extension,  which  then  is  made  on  the  arm  with  the  elbow 
flexed.      I  have  resorted  to  this  method  of  treatment  in  a  few  cases 


PERMANENT    EXTENSION. 


387 


of  infected   compound  fractures  of  the  humerus  with  signal  suc- 
cess. 

The  usual  method  of  appl}^ing  extension  is  to  fasten  two  strips 
of  adhesive  plaster  one  on  each  side  of  the  limb,  covering  a  suffi- 
cient surface  to  support  the  weight,  and  connect  them  with  a  cross- 
piece  of  wood  below,  to  which  the  extending  cord  is  tied.  The 
adhesive  plaster  not  infrequently  irritates  and  blisters  the  skin, 
more  especialh-  in  the  case  of  children  ;  at  other  times  the  skin   is 


\J^ 


Pig.  241. — Adhesive  pla.ster  cut  for  Buck's  extension  (Stimson). 


abraded  or  ulcerated,  when  some  other  method  of  securing  a  hold 
on  the  limb  must  be  devised.  Lead  plaster  is  less  likely  to  cause  irri- 
tation than  the  ordinary  rubber  plaster,  and  for  this  reason  it  should 
be  used  in  preference  to  the  latter.  In  children  and  in  subjects  with 
delicate  abraded  or  diseased  skin  cloth  instead  of  plaster  should 
be  used.  Strips  of  linen  are  fastened  with  collodion,  and  to 
increase  the  surface  for  traction  upon  the  limb,  and  to  secure  a 
better  hold  of  the  cloth  strips  on  the  skin,  thin  layers  of  absorbent 
cotton  are  placed 
along  the  borders 
and  across  the  strips, 
and  fastened  by  sat- 
urating the  cotton 
and  the  cloth  strips 
with  collodion.  Ex- 
tension made  on  a 
plaster-of-Paris  shoe 
or  boot  is  objection- 
able, as  decubitus 
upon  the  dorsum  of 
the  foot  is  very  likely 
to  occur.  If,  for  any 
reason,  this   method 

of  extension  is  used,  the  boot  or  shoe  should  be  lined  with  a  thick 
layer  of  absorbent  cotton  at  pressure  points.  Extension  would  be 
combined  with  mechanical  measures  that  will  prevent  eversion  and 
lateral  dis[)laccment.  A  long  outer  splint,  reaching  from  the  sole 
of  the  foot  to  the  axilla,  supplied  with  a  foot-board  and  well  padded, 
is  frequently  used  to  prevent  eversion.  A  posterior  splint  with  a  foot- 
board and  a  cross-piece  answers  the  same  purpose.  Two  long  sand- 
bags molded  to  the  sides  of  the  limb  fmiiish  a  good  lateral  support. 
Perhaps  the  best  device  yet  invented  to  prevent  eversion  and 
for  the  preservation  of  the  extending  force  is  the  sliding  foot-board 
of  Volkmann,  shown  in  figure  242.      The  pulley  over  whicJi  the  cord 


Fig.  242. — Volkmann's  sliding  foot-board. 


388  FRACTURES. 

makes  the  extension  must  correspond  with  the  axis  of  the  limb,  or  that 
part  of  the  limb  upon  which  the  extension  is  made.  This  often  makes 
the  use  of  a  second  pulley  necessary.  The  weight  making  the 
extension  must  necessarily  vaiy  according  to  the  age  of  the  patient, 
the  amount  of  muscular  resistance  to  be  overcome,  and  the  degree 
of  longitudinal  displacement  to  be  corrected,  the  variation  being 
from  five  to  twenty-five  pounds.  The  effect  of  extension  must  be 
noted  from  day  to  day,  until  the  shortening  has  disappeared  or  has 
been  reduced  to  a  minimum  degree.  The  maximum  weight  should 
never  be  used  first.  Beginning  with  a  minimum  or  medium  weight, 
it  is  increased  as  rapidly  as  the  comfort  of  the  patient  will  permit, 
until  the  object  for  which  the  extension  is  employed  is  reahzed, 
when  it  can  be  as  gradually  diminished.  Should  shortening 
again  set  in,  the  weight  is  again  increased.  In  fractures  of  the 
femur  the  extension  should  be  carried  beyond  the  knee-joint,  as 
prolonged  and  severe  traction  from  a  point  below  the  joint  often 
results  in  temporary,  and  sometimes  in  permanent,  damage  to  the 
joint.  The  same  effect  of  extension  is  realized  if  the  strips  of 
adhesive  plaster  or  the  extending  cloth  sling  is  carried  up  to  and 
even  beyond  the  seat  of  fracture,  as  when  the  extension  is  limited 
to  below  the  knee-joint.  Extension  alone  does  not  secure  the 
necessary  rest  for  the  seat  of  fracture,  which,  in  addition  to  the 
extension,  should  always  be  immobilized  by  lateral  splints  extend- 
ing on  the  outside  from  the  crest  of  the  ilium  to  the  knee-joint,  and 
on  the  inside  from  the  perineum  to  the  same  level  below.  An 
anterior  and  a  posterior  splint  will  add  materially  to  the  security  of 
fixation.  Four  splints  made  of  Gooch's  or  Esmarch's  splint  mate- 
rial, held  in  place  by  two  leather  straps,  constitute  the  ideal 
method  of  fixation  of  fractures  of  the  shaft  of  the  femur  treated  by 
extension.  Extension  must  be  continued  until  the  union  is  firm 
enough  to  guard  against  shortening, — that  is,  on  an  average  of  from 
four  to  six  weeks, — when  a  circular  plastic  splint  can  be  relied  upon 
in  preventing  angular  deformity.  Besides,  it  will  reheve  the  patient 
from  the  monotony  and  depressing  effects  of  confinement  in  bed,  and 
enable  him,  without  any  risk,  to  avail  himself  of  the  benefits  of 
exercise,  with  the  aid  of  crutches,  and  the  bracing,  tonic  effects  of 
outdoor  air, 

Malgaigne  hooks  and  spear,  the  former  for  the  treatment  of 
fracture  of  the  patella,  the  latter  for  oblique  fractures  of  the  leg 
with  marked  displacement  of  the  upper  fragment  of  the  tibia  for- 
ward, are  no  longer  used,  since  aseptic  surgery  has  made  it  com- 
paratively safe  to  resort  to  direct  means  of  fixation  in  cases  in 
which  these  instruments  were  formerly  employed. 

Direct  means  of  fixation,  so  strongly  urged  by  me  in  discuss- 
ing the  treatment  of  compound  fractures,  has  its  rigid  limitations 
in  the  management  of  subcutaneous  fractures.  The  conversion  of 
a  subcutaneous  into  an  open  fracture  is  attended  by  some  risk  and 
brings  additional  responsibilities   that  the  physician,  and  even  the 


REMOTE  CONSEQUENCES  OF  FRACTURE.  389 

expert  surgeon,  can  ill  afford  to  ignore.  Our  present  means  of 
procuring  asepsis  are  by  no  means  infallible,  and  the  treatment  of 
subcutaneous  fractures  b}'  the  open  method  of  reduction  and  direct 
means  of  fixation  by  nailing  or  suturing  must,  for  good  reasons,  be 
restricted  to  cases  in  which  the  best  external  mechanical  treatment 
would  be  inadequate  to  secure  a  satisfactory  result,  to  cases  in 
which  the  reduction  is  found  impossible,  and,  finally,  to  cases  in 
which  we  have  reason  to  belie\e  that  the  interposition  of  soft  tissues 
between  the  fragments  is  present  and  can  not  be  removed  by 
bloodless  attempts.  Fractures  of  the  clavicle  with  marked  dis- 
placement, irreducible  traumatic  fracture  of  the  epiphyses,  and 
fractures  of  the  patella  and  olecranon  process  are  some  of  the 
fractures  in  which  the  open  treatment  has  been  strongly  recom- 
mended from  influential  sources,  and  which,  even  in  the  minds  of 
the  most  conservative  practitioners,  will  bring  up  the  question  of 
the  propriety  of  resorting  to  direct  means  of  reduction  and  fixa- 
tion. With  the  necessary  care  in  effecting  reduction  and  maintain- 
ing retention,  the  cases  of  subcutaneous  fracture  justifying  the  open 
method  of  treatment  at  the  present  time  are  exceptional.  Suturing 
of  the  patella  in  recent  fractures  should  be  limited  to  ca.ses  in  which 
the  ligaments  of  the  joint  are  extensively  implicated,  in  which 
event  the  direct  intervention  is  resorted  to  more  for  the  purpose 
of  securing  a  satisfactor\-  healing  of  the  wound  of  the  soft  tissues 
than  with  a  view  of  obtaining  bony  union  of  the  fractured  patella. 

REMOTE  CONSEQUENCES  OF  FRACTURE. 

Ill  results  after  subcutaneous  fractures  under  the  best  treatment 
are  by  no  means  infrequent,  and  bad  results  attributable  to  careless, 
unskilful,  or  negligent  treatment  are  not  rare.  In  estimating  the 
shortcomings  of  treatment  in  the  latter  class  of  cases  the  physician 
should  be  his  own  critic  rather  than  a  critic  of  the  work  of  his 
colleagues,  as  he  should  remember  that  it  is  far  easier  to  criticize 
than  to  prevent  unfavorable  results.  The  conduct  of  the  patient 
himself  often  contributes  to  or  detracts  from  the  functional  result. 
The  same  treatment  pursued  in  a  patient,  confiding  subject  for 
the  .same  injury  will  result  more  favorably  than  if  the  patient  is 
irritable,  mistrusting,  and  refractory.  In  the  treatment  of  a  frac- 
ture the  patient  owes  a  duty  to  the  physician,  as  does  the  physi- 
cian to  the  patient,  and  it  is  a  disregard  of  duty  on  the  part  of  the 
former  that  is  as  often  responsible  for  a  bad  result  as  is  ignorance 
or  lack  of  attention  on  the  part  of  the  latter.  It  is  the  harmonious 
cooperation  between  a  good  patient  and  a  skilful,  careful,  and  at- 
tentive surgeon  that  overcomes  obstacles  in  the  treatment  of  a 
difficult  fracture  and  that  is  usually  rewarded  by  a  satisfactory 
functional  result.  A  late  examination  of  the  remote  ill  conse- 
quences of  fracture  does  not  always  give  a  clear  idea  of  the  nature 
and  gravity  of  the  injury,  nnich  less  of  the  difficulties  encoimtered 
on  all  sides  in  its  treatment.      Physicians  on  this  account  should  be 


390 


FRACTURES. 


slow  in  passing  judgment  on  the  work  of  their  colleagues,  as  much 
harm  has  resulted  to  able,  painstaking,  and  conscientious  practi- 
tioners and  the  profession  as  a  whole  from  injudicious  and  uncalled- 
for  interference  in  this  direction. 

Among  the  conditions  that  interfere  with  a  desirable  result  must 
be  mentioned,  foremost. 

Excessive  and  Defective  Callus  Formation. — Callus  formation 

depends  on  the  abun- 
dance and  functional 
activity  of  the  osteo- 
blasts in  the  periostewn 
and  inedidlary  tissue, 
the  principal,  if  not  the 
sole,  histologic  sources 
of  neiv  bone.  If  these 
calhis-fortning  agents 
are  in  excess  in  number 
and  activity,  or  if  they 
are  defective  in  number 
or  proliferating  poiver, 
the  physician  certainly 
can  not  be  blamed  for 
faulty  callus  produc- 
tion. The  intrinsic 
capacity  of  the  frac- 
tured bone  to  repair 
itself  must  be  taken 
into  due  consideration 
in  a  search  for  the 
many  causes  of  faulty 
callus  formation.  Ex- 
cessive traumatic 
stimulation  of  the  tis- 
sues by  comminution 
of  the  bone  and  dis- 
turbance of  the  frag- 
ments are  important 
agencies  in  excessive 
callus  production. 
Accurate  coaptation 
of  the  fragments  to  their  normal  relative  positions  and  immobili- 
zation at  the  seat  of  fracture  are  best  calculated  to  limit  callus 
production  to  normal  requirements.  Premature  passive  motion, 
imperfect  reduction,  and  defective  immobilization  are  the  three 
causes  attributable  to  faulty  treatment  that  contribute  to  the 
formation  of  a  massive  callus,  and  among  these  premature 
passive  motion  is  the  most  important.  Physicians,  as  a  rule, 
are    overanxious,    in    the    treatment    of    fractures    near    and    into 


Fig.  243. — Old  fracture  of  the  lower  end  of  the  humerus  ; 
massive  callus  formation  and  ankylosis. 


EXCESSIVE    AND    DEFECTIVE    CALLUS    FORMATION. 


391 


joints,  to  resort  to  early  passive  motion  for  the  purpose  of  pre- 
venting stiffness  or  ankylosis  of  the  joint.  Passive  motion  made 
before  union  by  bony  callus  has  taken  place  always  results  in 
motion  between  the  fragments,  as  the  short  fragment  on  the  side 
of  the  joint  can  not  be  immobilized,  and  the  mechanical  irritation 
thus  produced  stimulates  the  tissues  beyond  the  degree  required 
for  a  satisfactory 
union.  Passn  r  j  no- 
tion in  fractures  of 
the  epiphyseal  ex- 
tremities of  the  long 
bones  sJionld  invari- 
ably be  postponed 
until  the  fragments 
have  united  with 
sufficient  firmness 
to  guard  against 
disturbance  of  coap- 
tation by  the  move- 
ments. Premature 
passive  motion  is 
one  of  the  recog- 
nized causes  of  non- 
union, but  more  fre- 
quently it  impairs 
the  functional  result 
by  being  conducive 
to  the  foi'mation  of 
an  excessive,  luxur- 
iant callus,  which, 
by  its  proximity  to 
or  involvement  of 
important  Joi?its, 
mechanically  inter- 
feres zuith  the  res- 
toration of  the  nor- 
mal range  of  mo- 
tion. 

Among  the 
causes  of  excessive 
callus  production 
over    w  h  i  c  h     the 

physician  has  no  control  are  age,  .seat  of  fracture,  and  the  extent 
of  injury  of  the  soft  ti.ssues.  Callus  production  is  likely  to  be 
in  excess  of  normal  requirements  during  infancy,  childhood,  and 
adolescence — that  is,  during  the  time  of  life  when  the  o.steobla.sts 
are  actively  engaged  in  the  development  of  the  o.s.seous  sy.stem. 
Injury  of  the   soft  parts  has    always  been    considered  as  an  im- 


Fig.  244. — Fracture  of  both  bones  of  the  forearm  ;  de- 
fective callus  production  and  nonunion.  Extreme  atrophy 
of  lower  fragment  of  ulna.     Old  case. 


392 


FRACTURES. 


portant  element  in  the  production  of  callus.  It  is  well  known 
that  callus  formation  is  most  plentiful  on  the  side  of  the  fracture 
where  the  soft  tissues  are  most  abundant.  In  cases  of  exuberant 
callus  of  fracture  of  both  bones  of  the  leg  the  callus  is  always 
most  luxuriant  on  the  flexor  sides,  and  in  fractures  of  the  forearm 
it  is  most  profuse  on  the  anterior  side.      The  greater  vascularity  on 

the  side  of  the  bone  most 
profusely  supplied  with 
soft  tissues  has,  in  all 
probability,  more  to  do 
with  massive  callus  for- 
mation than  the  amount 
of  soft  tissues. 

The  seat  of  fracture 
has  a  decided  influence 
on  the  amount  of  callus 
production.  Fractures 
in  close  proximity  to 
joints,  for  reasons  that 
are  not  fully  understood, 
are  very  likely  to  give 
rise  to  profuse  callus 
formation  (see  Fig.  243). 
Fractures  in  the  epiphys- 
eal extremities  of  the 
long  bones  are  often 
fractures  characterized 
by  extensive  injury  to 
the  bone,  and  not  in- 
frequently complicated 
by  involvement  of  the 
adjacent  joint,  conditions 
that  give  rise  to  great 
vascularity,  and  its  usual 
inevitable  consequences, 
hypernutrition  and  great 
activity  of  cell  prolifer- 
ation. Premature  pas- 
sive motion  can  only  ag- 
gravate these  conditions, 
and,  unfortunately,  it  is  too  often  resorted  to  by  the  anxious,  zealous 
practitioner.  Incomplete  reduction  and  imperfect  immobilization 
are  two  causes  of  excessive  callus  formation  that  should  be  elimin- 
ated by  judicious  treatment. 

Defective  callus  formation  is  one  of  the  consequences  of  sup- 
puration in  compound  fractures,  and  in  simple  fractures  made  com- 
pound by  infection,  occurring  with  or  without  direct  operative 
interference.      The   suppurative    process   interferes   with   the  func- 


Fig.  245. — Fracture  of  both  bones  of  the  fore- 
arm. Union  of  fracture  of  radius  in  malposition.  Non- 
union of  radial  fracture  owing  to  defective  callus  for- 
mation. Operation  by  direct  treatment,  including 
wiring,  restored  the  continuity  of  the  bone.  Illumina- 
tion through  plaster-of- Paris  dressing. 


SUPPURATION. 


393 


Fig.  246. — Fracture  in  the 
upper  third  of  the  femur,  with 
great  longitudinal  and  angular 
displacement,  united  by  bony  callus 
with  the  pelvis  (Bruns). 


tional  activity  of  the  osteoblasts,   and   when   extensive   and    pro 

longed    in  compound   fractures,   may  interfere  with   callus  forma 

tion  sufficiently  to   prevent    union    by 

bony  callus. 

Suppuration    retards  but   does   not 

always  interfere  with  the  production  of 

a  normal   or  even  an  excessive  callus. 

After    the    subsidence  of  the  infective 

process,  the    osteogenetic   tissues  that 

remain  resume  their  legitimate  function, 

and  eventually  the  fracture  unites  by  a 

normal  or  even  an  exuberant  callus. 
Scanty  covering  of  soft  parts  has 

always    been  regarded   as  a  condition 

adverse  to  callus  production.     Pseudar- 

throsis  is  more  likeh'  to  occur  in  that 

part  of  a  limb  where  the  soft  tissues  are 

scanty.      It  is  beyond  the  power  of  the 

physician  to  eliminate  this  cause  of  de- 
fective   callus    formation.      When    this 

anatomic  cause  of  defective  callus  pro- 
duction presents  itself,  the  physician  is 

anxious  to  so  treat  the  fracture  as  to  utilize  all 
the  remaining  conditions,  in  order  to  place  the 
fragments  in  the  most  favorable  conditions  for 
speedy  and  satisfactory  union  by  bony  callus. 
Intra-articular  fractures  require  special  care  on 
the  part  of  the  physician  to  obtain  union  by  bony 
callus,  as  the  local  conditions  are  most  unfavor- 
able for  such  a  result.  Perfect  reduction  and 
permanent  fixation  are  the  indications  that  have 
to  be  fulfilled  to  the  maximum  extent  to  over- 
come the  anatomic  conditions  adverse  to  satis- 
factory callus  formation. 

Defective  local  and  general  nutrition  has  been 
greatly  overestimated  as  a  cause  of  defective  cal- 
lus formation  and  nonunion.  Complete  lateral 
and  extensive  longitudinal  displacements  are 
serious  causes  of  defective  callus  formation  and 
nonunion,  but  it  is  astonishing  to  what  an  extent 
the  reparative  processes  neutralize  these  unfavor- 
able conditions.  Nature's  resources  to  remedy 
such  conditions  are  best  demonstrated  in  frac- 
tures occurring  in  the  lower  animals,  where 
mechanical  treatment  is  out  of  question.  It  is 
in  cases  of  this  kind  that  the  osteogenetic  tissues, 

placed  in  the   most   unfavorable  condition  for  repair  of  the  injury, 

accomplish  the  difficult  task  of  restoring  the  continuity  of  the  bone 


Fig.  247. —Fi- 
brous l)and  of  union 
after  fracture  of  the 
patella  flloffai. 


394  FRACTURES. 

by  being  subjected  to  traumatic  irritation,  caused  by  the  displaced 
and  movable  fragments. 

Diastasis  of  the  fragments,  as  occurs  in  fractures  of  the  patella 
and  olecranon  process  and  in  nonimpacted  intra-articular  frac- 
tures, is  a  very  potent  cause  of  defective  callus  formation.  Accu- 
rate coaptation  and  fixation  of  the  fragments  are  conducive  to 
ideal  callus  production.  It  seems  that  a  certain  degree  of  intra- 
fragmentary  pressure  is  a  mechanical  condition  favorable  to  tissue 
stimulation,  as  was  pointed  out  long  ago  by  Sir  Astley  Cooper, 
and  is  best  seen  in  studying  the  process  of  repair  in  intra-articular 
fractures.  Among  the  more  common  remote  ill  consequences  of 
fractures  stand,  preeminent. 

Stiffness  and  Ankylosis  of  Joints. — Every  prudent  practitioner 
protects  his  own  reputation  and  avoids  a  source  of  disappointment 
to  his  patient  by  giving  a  very  guarded  prognosis,  as  far  as  recovery 
of  function  is  concerned,  in  all  cases  of  fractures  situated  near 
joints  or  involving  the  joint  itself  In  fractures  near  joints  defec- 
tive function  is  frequently  one  of  the  unavoidable  permanent  conse- 
quences of  the  injury.  A  change  of  direction  of  the  articular 
surfaces,  the  result  of  malposition,  excessive  callus  production, 
laceration  of-  the  ligaments,  loss  of  points  of  muscle  origin  or 
insertion,  are  some  of  the  more  important  conditions  that  impair 
the  functional  result.  Such  fractures  are  often  complicated  by 
dislocation,  complete  or  partial,  of  one  of  the  articular  extremities, 
a  condition  not  infrequently  overlooked  and  often  not  completely 
corrected. 

Instances  of  this  kind  are  observed  most  frequently  in  fractures 
near  or  extending  into  the  elbow-joint. 

Bony  ankylosis  is,  fortunately,  a  rare  occurrence,  but  must  be 
expected  when  the  joint  fracture  is  extensive,  when  it  extends  beyond 
the  limits  of  the  capsule,  and  especially  when  opposite  articular  ex- 
tremities are  fractured  at  the  same  time,  when  the  bony  callus  may 
span  the  joint  connecting  the  two  bones  by  a  bridge  of  new  bone. 
If,  from  the  nature  of  the  injury,  such  a  result  is  anticipated,  the 
prognosis  must  be  made  accordingly.  The  limb  is  placed  in  the 
position  in  which  it  will  be  most  useful  in  the  event  of  ankylosis — 
that  is,  in  fractures  involving  the  elbow-joint  the  forearm  is  flexed 
at  a  right  angle,  half-way  between  pronation  and  supination  ;  in  frac- 
tures of  the  hip-joint  the  thigh  is  slightly  flexed.  This  applies 
to  fractures  of  the  articular  ends  of  the  tibia  and  femur  in  fractures 
involving  the  knee-joint,  when  the  leg  should  be  slightly  flexed. 

Besides  abnormal  deviation  of  the  articular  surfaces  and  callus 
formation  invading  the  joint,  pathologic  conditions  affecting  the  soft 
tissues  of  the  joint  and  following  as  a  sequence  of  the  injury  may 
impair  seriously  the  function  of  the  joint.  One  of  the  common 
causes  of  stiffness  of  joints  after  fractures  is  intra-articular  extravasa- 
tion of  blood.  The  blood  in  the  joint  acts  as  a  foreign,  aseptic, 
absorbable  material.     It  is  usually  absorbed  rapidly  without  causing 


STIFFNESS    AND    ANKYLOSIS    OF    JOINTS. 


395 


anything  more  than  a  temporary  disturbance  of  function.  In  other 
cases,  however,  the  effusion  may  be  so  copious  that  harmful  intra- 
articular tension  may  become  a  source  of  danger  to  the  future 
utility  of  the  joint.  If  the  blood  is  not  absorbed  promptly,  its 
presence  acts  as  an  irritant,  when  the  synovial  membrane  becomes 
vascular  and  proliferates.  The  new  tissue  from  the  surface  of  the 
synovial  membrane  infiltrates  the  blood-clot,  and  an  intra-articular 


Fig.  248. — Fracture  of  the  ulna  with  forward  dislocation  of  the  head  of  the  radius. 

scar  or  adhesions  form,  resulting  in  stiffness  or  fibrous  ankylosis, 
which  not  infrequently  remains  as  a  permanent  remote  result  of  the 
fracture. 

Tendovaginitis  and  adhesions  of  muscles  or  tendons  to  the 
callus  or  between  themselves  are  among  the  most  common  causes 
that  lead  to  troublesome,  and  sometimes  to  permanent,  stiffness  of 
the  joint.  The  fr)rmation  of  these  adhesions  can  not  be  prevented, 
as  they  follow  injuries  to  the  soft  structures,  tears  of  the  tendon 


396  FRACTURES. 

sheaths,  laceration  of  muscles,  and  extravasation  of  blood.  Neg- 
lect on  the  part  of  the  physician  to  begin  the  treatment  of  such 
adhesions  as  soon  as  the  bone  has  united,  and  to  supervise  and 
continue  the  same  as  long  as  necessary,  is  responsible  for  many 
tardy  recoveries  and  permanent  disabilities.  Active  and  passive 
motion,  as  soon  as  union  is  sufficiently  firm  to  warrant  the  same, 
and  systematic  massage  constitute  the  most  effective  course  of 
treatment.  If  tendons  or  muscles  become  embedded  in  the  callus, 
the  functional  disturbances  from  this  cause  will  be  permanent. 

Atrophy  of  the  limb,  to  a  greater  or  less  extent,  is  one  of  the 
constant  results  of  fracture.  The  physiologic  atrophy  that  always 
sets  in  is  caused  by  n  on  use  of  the  limb,  and  is  called  inactivity 
atrophy,  which  disappears  in  a  short  time  upon  the  use  of  the 
limb.  Inactivity  atrophy  is  slight  unless  it  has  been  increased  by 
harmful  pressure,  which  is  often  the  case.  A  more  troublesome 
form  of  atrophy  is  the  result  of  trophoneurotic  influences  in  con- 
nection with  some  fractures,  but  this  kind  of  atrophy  is  rare  as 
compared  with  atrophy  associated  with  bone  and  joint  diseases 
from  the  same  cause. 

Thrombosis  and  Embolism. — Thrombosis  of  the  veins  at  the 
seat  of  fracture  must  occur  to  a  greater  or  less  extent  in  almost 
every  instance.  The  thrombosis  of  practical  importance  is  limited 
to  occlusion  of  veins  large  enough  to  cause  peripheral  symptoms  in- 
dicating venous  obstruction  and  to  be  a  cause  of  embolism.  Throm- 
bosis and  embolism  are  more  frequently  seen  in  infected  com- 
pound than  in  subcutaneous  fractures.  A  vein  of  considerable 
size  may  become  occluded  by  thrombosis  without  producing  visible 
external  manifestations.  Durodie  found,  in  each  case,  in  eight 
autopsies  made  from  the  fifth  to  the  thirtieth  day  after  the  fracture, 
thrombosis  of  the  deep  veins,  which,  in  some  cases,  had  extended  to 
the  large  vein-trunks.  Bruns  has  shown,  by  his  statistics,  that 
fractures  of  the  lower  extremity  are  most  frequently  the  seat  of 
thrombosis — in  45  out  of  53  cases. 

Thrombosis  occurs  more  frequently  in  adults  and  in  persons  of 
advanced  age  than  in  children.  Except  as  the  result  of  infection 
in  compound  fractures,  thrombosis  is  caused  by  laceration  or  com- 
pression of  veins  at  the  seat  of  fracture.  The  vein  injury  that 
determines  the  thrombosis  is  caused  by  the  fracturing  force,  by  the 
displaced  fragments,  or  the  thrombosis  follows  compression  that,  in 
the  majority  of  cases,  is  due  to  a  copious  extravasation  in  connec- 
tion with  the  resulting  diffuse  edematous  swelling  of  the  soft  tis- 
sues. In  most  of  the  cases  in  which  thrombosis  of  large  veins  was 
found,  either  by  external  manifestations  or  by  autopsy,  it  was  noted 
that  the  thrombosis  followed  a  severe  contusion  and  a  copious 
extravasation  of  blood.  Phlebitis  as  a  cause  of  thrombosis  is  only 
seen  in  compound  infected  fractures  ;  in  all  other  cases  the  throm- 
bus formation  is  due  to  the  immediate  effects  of  the  injury  and 
their  consequences.      Edematous  swelling  of  the  limb  points  to  the 


GANGRENE.  397 

existence  of  vcnoits  obstrnctio)i,  caused  by  thrombosis  of  the  principal 
vein  of  the  limb — the  axillary  in  the  upper,  and  the  femoral  in  the 
loiver,  extremity.  The  swelling  makes  its  appearance  usually  in  from 
two  to  four  weeks  after  the  injury. 

Embolism  is  a  very  rare  occurrence  in  cases  of  aseptic  throm- 
bosis of  the  veins.  Sudden  death  from  this  cause  is,  fortunately, 
very  rare.  Virchow,  in  1846,  called  attention  to  death  resulting 
from  embolism  in  cases  of  subcutaneous  fractures.  The  case  to 
which  he  referred  at  that  time  was  one  of  fracture  of  the  neck  of  the 
femur.  Bruns  has  collected  35  cases  of  embolism  complicating 
fracture,  and  of  these  30  died,  the  diagnosis  being  verified  in  23. 
The  accident  occurred  in  from  the  fourth  to  the  seventy-second  day 
after  the  injur}',  the  largest  number  between  the  thirteenth  and  the 
twentieth  day.  In  a  case  that  came  under  my  observation  sudden 
death  from  pulmonary  embolism  occurred  during  the  sixth  week 
after  the  fracture.  The  case  was  one  of'fracture  of  the  shaft  of  the 
femur  treated  by  continuous  extension.  The  bone  had  united,  and 
the  patient  was  expected  to  leave  the  hospital  the  next  day.  During 
the  night  he  sat  up  in  bed,  fell  back  unconscious,  and  died  in  a  few 
minutes,  death  being  preceded  by  the  characteristic  symptoms  of 
pulmonary  embolism. 

In  the  23  fatal  cases  of  embolism  verified  by  autopsy,  the  em- 
bolus was  found  twenty  times  in  the  pulmonary  artery  or  its 
branches,  and  three  times  in  the  right  side  of  the  heart.  If  the 
embolus  does  not  cause  death  from  the  immediate  effects  of  the 
obstructed  pulmonary  circulation,  the  patient's  life  remains  in  dan- 
ger from  the  more  remote  effects  of  the  pulmonary  infarct — pneu- 
monia and  pulmonary  gangrene.  I  remember  a  case  of  pulmonary 
embolism  that  occurred  three  weeks  after  the  fracture,  the  patient 
narrowly  escaping  death  from  the  immediate  effects  of  the  accident. 
After  the  acute  symptoms  had  subsided,  the  patient  appeared  to 
improve  steadily,  when,  two  days  later,  pneumonia  set  in,  which 
again  threatened  his  life  for  more  than  a  week. 

Gangrene. — Gangrene  of  an  entire  limb  below  the  seat  of  fracture 
indicates  the  coexistence  of  injury  of  the  principal  blood-vessels  or 
arrest  of  the  circulation  by  pressure  caused  by  a  displaced  fragment 
or  a  faulty  dressing.  Gangrene  from  vessel  injury  can  not  be 
avoided,  neither  can  it  always  be  predicted  at  the  time  the  first 
examination  is  made.  Gangrene  from  compression  should  be  pre- 
vented by  effecting  complete  reduction  and  by  resorting  to  all 
precautions  to  guard  against  harmful  localized  or  circular  compres- 
sion. Localized  gangrene  of  the  skin  caused  by  a  faulty  dressing 
may  extend  by  the  infection  becoming  diffuse,  eventually  necessi- 
tating amputation  as  a  life-saving  measure. 

(Jnc  cause  of  gangrene  that  is  so  seldom  recognized  at  the  time 
the  first  examination  is  made  is  cru.shing  or  tearing  of  the  intima 
of  the  principal  artery  of  the  limb,  the  former  produced  by  contu- 
sion, the  latter  by  a  traction  injury.      If  the  manner  in  which  the 


398  FRACTURES. 

injury  was  inflicted  should  point  to  the  possible  existence  of  so 
serious  a  complication,  the  most  thorough  search  for  evidences  of 
disturbance  of  the  peripheral  circulation  must  be  made,  in  order  to 
determine  the  existence  of  serious  vascular  complications.  A  de- 
cided diminution  in  the  intra-arterial  tension  and  feeble  capillary  cir- 
culation with  venous  engorgement  are  conditions  that  should  arouse 
the  suspicion  of  injury  to  the  inner  coat  of  the  artery.  Complete 
arrest  of  circulation  will  occur  in  such  cases  in  the  course  of  a  few 
days,  from  arterial  thrombosis.  Simultaneous  injury  of  the  princi- 
pal vein,  or  vein  compression  from  blood  extravasation,  will  hasten 
the  gangrene  and  favor  its  rapid  extension.  Harmful  circular  com- 
pression in  such  instances  will  be  productive  of  the  most  serious 
consequences,  and  must  be  carefully  guarded  against  by  immobil- 
izing the  limb  in  a  way  that  will  entirely  eliminate  this  additional 
source  of  danger  to  the  circulation  and  the  vitality  of  the  injured 
limb. 

Fat  embolism  has  already  been  discussed  in  connection  with  the 
immediate  results  of  the  injury,  as  it  constitutes  one  of  the  earliest 
complications  of  fractures.  It  is  again  alluded  to  here  because  the 
infarcts  that  may  occur  in  cases  that  recover  from  the  immediate 
effects  of  fat  embolism  are  liable  to  be  followed  by  pulmonary 
complications.  In  all  cases  in  which  this  result  of  fractures  is 
suspected  it  becomes  necessary  to  investigate  the  condition  of  the 
lungs  repeatedly,  by  making  a  thorough  physical  examination  from 
time  to  time,  and  by  looking  carefully  for  symptoms  that  accom- 
pany and  follow  pulmonary  infarcts.  Rapid  respiration,  imperfect 
oxygenation  of  the  blood,  cough,  hemoptysis,  pain,  and  defective 
respiratory  movements  of  the  affected  side  of  the  chest  are  the 
most  prominent  and  rehable  indications  of  the  onset  of  pulmonary 
complications  following  an  infarct  from  fat  embolism. 

Hemorrhage  in  subcutaneous  fracture  always  presents  itself  in 
the  form  of  an  interstitial  infiltration  or  extravasation.  If  an  artery 
of  considerable  size  has  been  completely  torn  by  the  fracturing 
force,  or  if  it  has  been  pierced  or  cut  by  a  sharp  fragment,  the 
primary  swelling  appears  rapidly.  Its  size  will  depend  on  the 
looseness  or  compactness  of  the  tissues  around  the  injured  vessel. 
A  swelling  that  appears  very  rapidly  and  reaches  its  maximum  size 
in  a  short  time  usually  indicates  arterial  hemorrhage.  If  the 
principal  artery  of  the  limb  is  the  source  of  the  bleeding,  the  per- 
ipheral pulse  disappears  and  other  indications  of  arrest  of  the 
circulation  will  soon  make  their  appearance.  Hemorrhage  from  an 
artery  of  considerable  size  will  cause  a  swelling  of  the  limb,  which 
appears  rapidly  and  which  may  interfere,  by  pressure,  with  the  estab- 
lishment of  a  satisfactory  collateral  circulation.  The  limb  at  the 
seat  of  fracture  is  swollen,  the  skin  tense,  and  the  superficial  circu- 
lation feeble.  The  swelling  is  often  so  tense  that  fluctuation  can 
not  be  detected.  In  hemorrhage  from  small  arteries  and  veins  the 
swelling  increases  more  gradually  in  size  and  tension  is  less  marked. 


DECUBITUS.  399 

Puncture  of  an  artery  by  a  sharp  fragment  not  infrequently  is 
followed  by  the  development  of  a  traumatic  aneurysm,  and  if  the 
fragment  should,  at  the  same  time,  penetrate  the  accompanying 
vein,  an  arteriovenous  aneur}'sm  that  will  develop  later  will  reveal 
the  nature  of  the  vessel  injur}\ 

Central  Nervous  System. — The  central  nervous  system  is 
liable  to  become  implicated  in  fractures  in  the  same  manner  and  for 
the  same  reasons  as  in  injuries  of  the  soft  tissues  of  similar  gravity. 
Following  the  shock,  the  immediate  effect  of  the  injury,  muscular 
spasms  occur  and  add  greatly  to  the  difficulties  in  immobilizing  the 
injured  limb. 

Delirium  tremens,  in  persons  addicted  to  the  excessive  use  of 
alcohol,  is  a  remote  complication  fraught  with  danger  to  life,  and 
one  that  will  tax  the  ingenuity  of  the  surgeon  to  the  utmost  in 
devising  a  method  of  immobilizing  the  fracture  without  endangering 
the  circulation  of  the  injured  limb.  Rest  in  bed  and  immobiliza- 
tion of  the  fractured  limb  in  a  circular  plastic  splint  with  a  thick 
lining  of  an  absorbent  elastic  material,  such  as  absorbent  cotton, 
will  constitute  the  safest  treatment  until  the  patient  recovers  from 
the  effects  of  the  nervous  complication. 

Delirium  traumaticum  is  most  likely  to  develop  in  persons 
with  a  high-strung  nervous  temperament,  hereditary  or  acquired. 
The  treatment  of  the  fracture  will  be  the  same  as  in  delirium  tremens, 
until  the  patient  regains  the  normal  composure  of  the  nervous 
system. 

Prolonged  dorsal  recumbency  frequently  leads  to  complications 
that  ma}^  endanger  the  life  of  the  patient.  In  persons  advanced  in 
years  or  debilitated  by  previous  disease  hypostatic  pneumonia  is 
very  liable  to  occur.  Pneumonia  produced  by  such  a  cause  is 
usually  masked,  lacking  the  classic  symptoms  that  characterize, 
clinically,  croupous  pneumonia.  The  disease  sets  in  insidiously, 
and  is  very  often  overlooked  unless  the  physician  takes  the  precau- 
tion to  watch  for  the  symptoms  and  makes,  as  he  should,  frequent 
physical  examinations  of  the  chest. 

Decubitus  is  another  remote  complication  of  fractures  requir- 
ing in  their  treatment  prolonged  dorsal  recumbency.  The  danger 
from  this  source  is  greatest  in  fractures  of  the  spine  at  any  age. 
Obesity  is  another  predisposing  cause.  Under  the  conditions 
mentioned,  the  occurrence  of  this  remote  complication  should  be 
anticipated,  and  the  necessary  prophylactic  treatment  resorted  to  in 
time — an  elastic  bed,  alternate  pressure  by  the  use  of  air-pillows, 
washing  the  skin  with  a  50  per  cent,  solution  of  alcohol,  besides 
enforcing  cleanliness.  If  decubitus  is  inevitable,  the  necessary 
care  should  be  exercised  to  prevent  infection  of  the  devitalized  tis- 
sues by  appropriate  antiseptic  precautions.  The  skin  should  be 
thoroughly  disinfected  in  the  usual  way,  dusted  freely  with  boro- 
salicylic  powder,  and  covered  with  a  cushion  of  cotton  well  im- 
pregnated with  the  same  preparation,  and  held  in  place  with  strips 


400  FRACTURES. 

of  adhesive  plaster  and  a  gauze  roller.  Aseptic  necrosis  does  not 
expose  the  patient  to  any  risk  to  life,  and  limitation  of  the  necrotic 
process  can  be  confidently  expected,  while  moist  gangrene  is  noted 
for  its  intrinsic  tendency  to  progressive  extension  and  the  danger  to 
life  from  general  sepsis. 

Painful  Callus. — A  callus  extending  beyond  the  space  between 
the  fragments  is  likely  to  become  a  source  of  pain  by  encroaching 
upon  the  nerves  in  the  immediate  vicinity  of  the  seat  of  fracture.  A 
painful  callus  is,  with  few  exceptions,  an  exuberant  callus.  Displaced 
fragments  or  an  excessive  callus  may,  by  pressure  and  irritation,  in- 
volve adjacent  nerve-trunks,  producing  neuralgia  and  neuritis — com- 
plications that  are  characterized  by  pain  that  is  usually  attributed  to 
the  luxuriant  callus,  which  in  itself  is  painless,  but  which,  by  com- 
pression and  irritation,  is  productive  of  painful  affections  of  the 
nerves. 

Paralysis. — Paralysis  as  a  complication  of  subcutaneous  frac- 
tures makes  its  appearance,  when  it  does  occur,  either  immediately 
after  the  injury,  when  it  is  caused  by  division,  laceration,  or  contu- 
sion of  one  or  more  of  the  principal  nerve-trunks  by  either  the 
fracturing  force  or  by  the  displaced  fragments,  or  it  sets  in  later  in 
consequence  of  compression  caused  by  displaced  fragments  or  by 
the  callus.  Paralysis  produced  by  the  immediate  effects  of  the 
injury  should  be  detected  at  the  time  the  first  examination  is  made, 
which  should  always  include  a  search  for  nerve  injury.  This  is  not 
done  so  often  as  it  should  be,  and  consequently,  if  days  or  weeks 
later  paralysis  is  discovered,  it  is  more  difficult  to  interpret  its  essen- 
tial cause.  If,  on  first  examination,  nerve  function  below  the  seat 
of  fracture  is  found  intact  and  paralysis  makes  its  appearance  later, 
it  is  reasonable  to  exclude  the  immediate  effects  of  the  injury  as  an 
etiologic  factor  and  connect  it  with  displacement  of  fragments  or 
compression  on  the  part  of  the  callus. 

Delayed  Union  and  Pseudarthrosis. — A  sharp  clinical  and 
pathologic  distinction  must  be  made  between  delayed  union  and 
pseudarthrosis.  A  delayed  union  signifies  a  slow  process  of  repair  ; 
a  pseudarthrosis  indicates  an  incapacity  of  the  tissues  to  repair  the 
injury,  or  the  existence  of  mechanical  difficulties  that  intercept  the 
process  of  repair.  Delayed  union  means  a  paucity  of  osteoblasts, 
a  low  degree  of  their  capacity  to  proliferate,  or  abnormal  retarda- 
tion of  the  conversion  of  the  new  material  into  bone.  It  is  strange, 
but  nevertheless  true,  that  delayed  union  and  pseudarthrosis  are 
most  likely  to  occur  in  the  vigorous  adult  rather  than  in  the  debili- 
tated, marasmic,  and  the  aged. 

Pseudarthrosis  presents  itself,  pathologically,  in  two  distinct 
forms  :  (i)  Ligamentous  union  ;  (2)  interposition  between  the  frag- 
ments of  a  new  joint.  In  either  event  the  continuity  of  the  bone 
is  permanently  destroyed.  According  to  Agnew's  table,  the  relative 
frequency  of  false  joints  in  fractures  of  the  long  bones  is  as  fol- 
lows :  Femur,  155;  leg,  180;  humerus,  219;  forearm,  j6.      Frac- 


PSEUDARTHROSIS. 


401 


tures  of  the  humerus  at  the  junction  of  the  middle  with  the  lower 
third  figure  the  most  prominently  in  statistics  of  false  joints. 

A  delayed  union  is  a  union  that  may  be  effected  in  the  course 
of  several  months  and  even  a  year  or  more.  I  observed  a  case  of 
fracture  of  the  femur  a  year  and  a  half  after  the  accident,  in  which 
the  fragments  overlapped  one  another  and  no  bony  union  had  taken 
place.  After  the  frag- 
ments were  adjusted,  un- 
der the  influence  of  an 
anesthetic  and  under 
treatment  by  continuous 
extension  and  immobili- 
zation by  G  o  o  c  h ' s 
splints,  union  took  place 
in  the  course  of  two 
months.  As  has  already 
been  stated,  delayed 
union  occurs  either  in 
consequence  of  slow  cal- 
lus formation  or  retarda- 
tion of  the  transforma- 
tion of  the  products  of 
tissue  formation  into 
bone.  The  physician 
will  exercise  his  patience 
and  perseverance  in  the 
mechanical  treatment  of 
fractures  that  manifest 
such  reparative  defect, 
and  his  efforts  will  even- 
tually be  rewarded  by 
success. 

In  pseudarthrosis 
the  false  point  of  motion 
remains,  and  callus  for- 
mation is  inadequate  or 
entirely  wanting.  Fi- 
brous union  between  the 
fragments  means  either 
the  absence  of  bone-pro- 
ducing   tissues   between 

the  fragments,  or  a  lack  of  intrinsic  power  of  the  new  tissues  to 
undergo  transformation  into  bone.  Hruns  collected  56  cases  of 
fibrous  union,  shown  as  such  by  autopsy.  The  femur  was  the  seat 
of  fracture  in  22,  the  humerus  in  18,  and  the  forearm  and  leg  in 
8  each. 

The  most  important  cause  of  fibrous  union  is  the  distance  sepa- 
rating the  fragments.      Fibrous  union  is  expected  in  most  cases  of 
26 


Fig.  249. — Nonunited  fracture  of  the  tibia.  An- 
teroposterior illumination.  No  callus.  Short  liga- 
mentous union  between  the  two  oblique  fracture  sur- 
faces (Clinic,  Rush  Medical  College). 


402 


FRACTURES. 


fractures  of  the  patella  and  the  olecranon  process.  It  is  also  the 
usual  method  of  repair  in  intra-articular  fractures  of  the  neck  of  the 
femur  and  humerus  without  impaction.  The  next  most  frequent 
cause  is  interposition  of  soft  tissues  between  the  fragments.  Loss 
of  bone  tissue  is  another  important  etiologic  element  in  the  failure 
of  consolidation  by  bone.  In  fractures  that  heal  by  fibrous  union 
the  medullary  cavity  of  the  fragments  becomes  obliterated,  the  ends 

of  the  bone  become 
more  or  less  conic 
by  absorption,  and 
the  length  of  the 
ligament  will  de- 
pend on  the  dis- 
tance between  the 
fragments  and  the 
degree  of  mobility, 
on  the  strength  of 
the  ligament,  and 
the  length  of  the 
space  between  the 
fragments.  Callus 
formation  in  such 
cases  is  either  en- 
tirely absent  or,  at 
least,  inadequate  to 
bridge  the  space 
between  the  frag- 
ments. It  appears 
that  in  some  cases 
callus  production 
progresses  to  what 
appears  as  the  re- 
quisite extent, 
when  resorption  of 
the  new  material 
takes  place  and  the 
breach  of  continuity 
is  repaired  by  the 
interposition  of  fi- 
brous material.  If 
the  fractured  sur- 
faces are  separated  to  any  considerable  extent,  atrophy  of  the  ends 
of  the  bone  occurs  ;  if  they  are  opposite  each  other  and  in  near 
contact,  they  are  ground  off  and  polished  in  the  course  of  time. 
In  some  cases  they  are  covered  with  cartilage,  and  in  exceptional 
cases  a  true  joint  with  synovial  lining  is  interposed  between  the  ends 
of  the  fragments,  constituting  a  true  nearthrosis.  The  genuine  char- 
acter of  joint  formation  in   such  cases  has  been  demonstrated  by 


Fig.  250. — Fracture  of  both  bones  of  the  leg.  Great 
shortening  by  overlapping  of  fragments.  Fibula  united. 
Fibrous  union  of  fracture  of  tibia. 


PSEUDARTH  ROSIS. 


403 


diseases  that  may  afifect  the  joints,  being  of  the  same  nature  and 
character  as  similar  affections  of  normal  joints,  such  as  arthritis 
deformans  and  loose  bodies.  Of  the  latter  affection  of  false  joints, 
Bruns  has  collected  seven  cases,  of  which  number  the  humerus  was 
the  seat  of  nearthrosis  four  times,  the  forearm  twice,  and  the  leg 
once. 

Among  the  causes  of  delayed  union  and  pseudarthrosis 
rickets,  syphilis,  pregnancy,  lactation,  marasmus,  and  acute  infec- 
tive diseases  are  usually  enumerated  as  general  influences  that  re- 
tard callus  formation  and  transformation  of  the  new  material  into 
bone.  Among  the  local  causes  are  included  displacements  of  the 
fragments,  interposition  between  the  fragments  of  soft  tissues  and 
foreign  bodies,  defective  innervation  and  blood 
supply,  inflammation  of  the  surface  of  the  limb, 
and  loss  of  bone  substance.  Faulty  treatment 
contributes  to  such  an  occurrence,  and  among 
the  faults  must  be  mentioned  excessive  applica- 
tion of  cold,  imperfect  reduction  and  immobili- 
zation, harmful  circular  compression,  early  pas- 
sive motion,  and  premature  use  of  the  injured 
Hmb. 

The  treatment  of  delayed  union  consists  in 
removing  mechanical  causes  that  interfere  with 
normal  repair  of  the  injury  and  stimulation  of 
the  tissues  at  the  seat  of  fracture.  If,  after  the 
expiration  of  the  usual  length  of  time,  union  by 
bony  consolidation  fails  to  develop,  the  treatment 
is  so  modified  that  it  will  be  more  conducive  to 
callus  formation.  Active  use  of  the  limb,  im- 
mobilized by  an  immovable  dressing,  is  one  of 
the  simplest  means  to  increase  the  vascular  supply 
and  to  stimulate  the  process  of  repair.  A  more 
vigorous  circulation  thus  produced  may  also 
prove  adequate  in  transforming  an  immature 
callus  into  bone,  which,  without  such  stimulation,  might  possibly 
become  absorbed  or  fail  to  undergo  such  metaplastic  transition.  If 
delayed  union  is  the  result  of  imperfect  reduction,  this  defect  must 
be  corrected  by  tearing  up  existing  adhesions  and  effecting  accurate 
coaptation  with  the  aid  of  a  general  anesthetic.  Light  elastic  con- 
striction above  and  below  the  seat  of  fracture,  as  advised  by  Dum- 
reicher  and  Helferich,  to  secure  a  venous  congestion  of  the  parts 
in  order  to  furnish  the  material  for  the  callus,  has  been  found  useful 
in  cases  in  which  delayed  callus  formation  could  be  attributed  to  a 
defective  blood  supply. 

Amos  Graves,  of  San  Antonio,  in  his  very  extensive  experience 
in  emergency  surgery,  has  resorted,  for  many  years,  to  a  somewhat 
novel  j;rf;cc(lure  in  .stimulating  the  tissues  to  a  more  active  i)roce.ss 
of  repair.      Me  imitates  the  useful  effects  of  walking  in  such  cases 


Fig.  251. — Frac- 
ture of  the  olecranon 
healed  with  diastasis 
and  ligamentous  union 
(Bruns). 


404 


FRACTURES. 


by  instructing  the  patient  to  push  the  fragment  together  somewhat 
violently  by  pounding,  the  limb  being  properly  immobilized.  In 
fractures  of  the  forearm  the  blows  are  directed  against  the  knuckles 
of  the  fist,  the  elbow  resting  against  a  firm  support.  In  fracture 
of  the  humerus  the  force  is  applied  by  the  patient  striking  the 
elbow  against  a  firm  support.  In  fractures  of  the  leg  and  thigh 
the  patient  stands  on  the  opposite  limb,  leaning  on  a  chair  or  table, 

and  stamping  the  foot 
of  the  injured  limb  on 
the  floor.  The  sittings 
should  be  continued  for 
from  ten  to  fifteen  min- 
utes, and  repeated  fre- 
quently during  the  day. 
It  is  very  easy  to  con- 
ceive how  this  addi- 
tional treatment  would 
favorably  influence  the 
production  and  devel- 
opment of  callus,  and  it 
is  so  simple  and  safe 
that  it  recommends  it- 
self favorably  to  the 
attention  of  the  profes- 
sion. Massage  is  an- 
other therapeutic  re- 
source of  considerable 
value  in  such  cases,  and 
if  the  fragments  are 
held  in  proper  position 
while  it  is  applied,  can 
do  no  harm,  while  the 
vascular  stimulation 
and  improved  nutrition 
following  its  use  will 
influence  favorably  the 
bone-producing  func- 
tion of  the  osteoblasts. 
Broca  speaks  encour- 
agingly of  the  descend- 
ing galvanic  current  as 
a  remedy  in  stimulating  callus  production.  Finally,  the  injection 
of  from  three  to  ten  drops  of  a  lo  per  cent,  solution  of  chlorid  of 
zinc  between  and  around  the  fragments  is  a  very  potent  tissue 
stimulant,  and  may  be  tried  with  advantage  in  expediting  the  pro- 
cess of  repair  in  delayed  union. 

Time   is   a  relative   element   in   making   a   distinction    between 
delayed     union    and     pseudarthrosis.      In    some     cases   a    pseud- 


Fig.  252. — Fracture  of  both  bones  of  the  leg. 
Union  of  fibula  with  overlapping  of  fragments.  Non- 
union of  fracture  of  the  tibia. 


PSEUDARTH  ROSIS, 


405 


arthrosis  is  established  immediately  after  the  injury  has  occurred, 
by  the  interposition  of  soft  tissues  between  the  fractured  ends,  in 
quantity  and  structure  calculated  to  furnish  a  permanent  barrier 
against  union  by  bony  callus,  while,  as  I  have  found,  some  fractures 
in  which  union  was  delayed  for  more  than  a  year  eventually  united 
b}'  bony  consolidation.  Some  fractures,  especially  in  children, 
unite  firml}'  in  less  than  three  weeks,  while  in  others  the  process  of 
repair  is  not  completed  in  less  than  from  three  months  to  a  year. 
In  all  cases  of  delayed  union  it  becomes  necessaiy  to  search  for 
and  to  correct  constitu- 
tional causes  b}'  appro- 
priate general  treatment. 
The  internal  use  of  minute 
doses  of  phosphorus  de- 
serves a  trial  in  case  no 
general  cause  for  the  de- 
layed union  can  be  found. 

From  a  practical 
standpoint,  pseudarthrosis 
is  represented  by  a  condi- 
tion at  the  seat  of  fracture 
that  excludes  the  possi- 
bilit}^  of  the  restoration 
of  the  continuity  of  the 
bone  by  bony  consolida- 
tion, without  active  inter- 
ference. In  fractures  of 
the  leg  and  thigh  that  fail 
to  unite  in  the  expected 
time,  the  walking  appara- 
tus of  H.  H.  Smith  will 
not  only  enable  the  patient 
to  walk  about,  but  the  im- 
proved local  conditions 
arising  from  the  active  ex- 
ercise will  occasionally  re- 
sult in  late  consolidation 
by  bony  callus.  Acu- 
puncture and  subcuta- 
neous scarification  of  the  ends  of  the  fragments  are  seldom  em- 
ployed at  the  present  time  in  the  treatment  of  pseudarthrosis.  The 
seton,  so  highly  praised  by  S.  D.  Gross,  Physick,  and  others,  has 
become  almost  entirely  obsolete  as  a  therapeutic  agent  in  promot- 
ing the  healing  of  a  fracture.  Acupuncture,  combined  with  the 
galvanic  current,  has  been  suggested  and  tried,  but  the  results  have 
not  been  sufficiently  encouraging  to  claim  the  confidence  of  the 
modern  surgeon. 

One  of  the   oldest   methods  of  treatment  of  pseudarthrosis  is 


I'ijT.  253. — Fracture  of  tibia  and  fibula.  Fib- 
ula united  by  bony  callu.s.  Interposition  of  a  false 
joint  between  fragments  of  the  tibia. 


Fig.    254. — Apparatus  for   delayed  and   ununited    fractures:     A,    For   arm;     B,    for 
forearm  (after  H.  Smith). 


Fig.  255- — Brainard's  bone  drills. 


Fig.  256. — F.  H.  Hamilton's  bone  drills  with  guard. 


Fig.  257. — Langenbeck's  bone  drills. 


PSEUDARTHROSIS. 


407 


the  transformation  of  an  old  into  a  recent  fracture  by  manual  force. 
Under  the  influence  of  a  general  anesthetic  existing  adhesions  are 
torn  by  bending  the  limb 
at  the  seat  of  fracture  in 
different  directions,  fol- 
lowed by  rubbing  the 
fragments  together,  after 
which  they  are  carefully 
coaptated  and  immobil- 
ized in  the  same  manner 
as  a  recent  fracture. 

Subcutaneous  per- 
foration of  the  bone-ends 
with  a  drill,  introduced 
by  Daniel  Brainard  in 
1 840,  has,  after  an  exten- 
sive trial,  remained  as  a 
reliable  and  safe  opera- 
tion in  the  treatment  of 
delayed  union  and  pseu- 
darthrosis.  Through  the 
same  puncture  in  the 
skin  the  ends  of  the  frag- 
ments are  perforated  in 
different  directions.  The 
perforation  opens  up  new 
medullary  spaces  and  the 
medullary  canal  on  one 
or  both  .sides,  stimulating 
the  tissues  and  opening 
up  new  channels  for  the 
products  of  tissue  pro- 
liferation in  bridging  the  space  between  the  fragments.  The  pro- 
cedure is  repeated    every  two  or  three   weeks   until    the  fracture 


Fig.  258. — Apparatus  for  delayed  and  ununited 
fractures :  A,  For  thigh  ;  B,  for  leg  (after  H.  H. 
Smith). 


J^'g-  259. — Fastening  two  overlapping  fragments  together  with   two  ivory  nails  (Bruns). 


promi.scs  to   unite  by  bone,  or  until  the  attempts  at  effecting  union 
by  bony  callus  have  proved  unavailing. 

In  1846  Dieffenbach  recommended  the  use  of  ivory  pegs,  claim- 
ing that  the  foreign   substance   driven   into  the  ends  of  the  bone 


4o8 


FRACTURES. 


would  be  more  productive  of  callus  than  simple  perforation — an 
assertion  fully  warranted  by  subsequent  experience.      If  Brainard's 

drilling  operation  fails,  it 
may  be  followed  by  the  em- 
ployment of  aseptic  ivory 
or  bone  nails,  as  the  pres- 
ence of  the  foreign  sub- 
stance adds  another  stimu- 
lus in  arousing  the  tissues 
to  a  more  active  process  of 
repair. 

Direct  operative  inter- 
ference by  resection  of  the 
bone-ends  was  introduced 
by  White  in  1760.  Since 
then  the  operation  has  been  modified  by  following  the  resection  by 
direct  means  of  fixation — nailing  or  suturing.      Aseptic  absorbable 


Fig.  260. — Volkmann's  method  of  uniting 
fragments  in  the  operation  for  pseudarthrosis 
(Bruns). 


Fig.  261. — Pseudarthrosis  of  the  tibia,  with  extensive  loss  of  substance.  Im- 
paction of  the  lower  end  of  the  fibula  into  the  upper  fragment  of  the  resected  tibia 
(after  Hahn). 


Fig.  262. — Bone  transplantation  in  the  treatment  of  pseudarthrosis  of  the  ulna  (after 

Nussbaum). 


PSEUDARTHROSIS. 


409 


nails  of  ivory  or  bone  and  sutures  of  silver  wire  or  strong  catgut 
are  now  used  almost  exclusively  for  fastening  the  vivified  fragments 
together.  Resection  should  never  be  made  by  cutting  the  bone-ends 
transversely ,  as  it  is  very  important  to  sacrifice  as  little  of  the  bone 
tissue  as  possible  and  to  secure  the  largest  bone  s7/rfaces  obtainable 
for  coaptation.  The  fragments  sho7ild  be  vivified  obliquely  or  in  the 
shape  of  a  step,  as  advised  by  Volkmann,  and,  if  possible,  the  frag- 
jnents  removed  in  zdvifying  the  ends  should  not  be  completely  detached, 
but  should  be  re- 
tained and  fixed  in 
a  place  where  they 
may  be  utilised  in 
the  subsequent  re- 
parative process. 
The  methods  of 
wiring  and  other 
means  of  direct  fix- 
ation will  be  fully 
described  in  the 
chapter  on  Com- 
pound Fractures. 

The  exposure 
of  a  false  joint  for 
the  purpose  of 
transforming  an  old 
into  a  new  fracture, 
and  of  substituting 
direct  for  indirect 
means  of  fixation, 
should  only  be  seri- 
ously entertained 
after  other  methods 
have  had  a  fair  trial 
in  securing  healing 
of  the  fracture  by 
bony  callus.  In 
some  ca.ses  of  frac- 
ture of  the  hum- 
erus or  femur  or  fracture  of  two  parallel  bones,  with  great  loss  of 
substance  of  one,  coaptation  and  fixation  b\'  impaction  offer  the 
best  prospects  of  bony  consolidation.  If  the  impaction  can  not  be 
maintained  by  an  external  dres.sing,  direct  fixation  by  wiring,  nail- 
ing, or  the  u.se  of  the  bone  ferrule  is  indicated  and  will  add  greatly 
to  the  success  of  the  operation. 

In  false  joints  caused  by  great  loss  of  bone  tissue  it  may  become 
necessary  to  resort  to  transplantation  of  bone.  Implantation  of 
bone  from  any  of  the  lower  animals  has  invariably  proved  a  failure. 
In  the  cases  in  which  the  operation  appeared  to  have  been  successful, 


Fig.  263. — Pseudarthrosis  following  gunshot  fracture 
of  the  radius,  some  of  the  bird  sliot  remaining  embedded 
in  the  tissues. 


4IO 


FRACTURES. 


and  were  reported  as  being  so,  the  implanted  bone  was  absorbed  and 
replaced  by  new  bone,  produced  by  the  osteogenetic  tissues  around 
the  foreign  aseptic  substance.  The  results  of  experiments,  as  well 
as  a  large  clinical  material,  have  proved  that  autotransplantation 
is  the  proper  method  to  pursue  in  such  cases.  The  material  for  the 
transplantation  should  be  taken,  if  possible,  from  the  same  bone,  by 
chipping  off  fragments  from  the  bone-ends,  as  will  be  described  in 

the  chapter  on  Compound 
Fractures,  or,  in  case  the 
operation  is  made  on  one 
of  two  parallel  bones,  from 
the  bone  opposite,  preserv- 
ing, if  possible,  some  of  the 
vascular  connections. 

The  first  successful 
bone  transplantation  in  the 
treatment  of  pseudarthrosis 
was  made  by  von  Nuss- 
baum.  The  ulna  was  the 
seat  of  fracture,  and  a  por- 
tion long  enough  to  bridge 
the  space  was  taken  from 
one  of  the  fragments,  with 
which  it  remained  connect- 
ed by  a  periosteal  bridge. 
Nussbaum  placed  great 
stress  on  preserving  vas- 
cular connection  between 
the  fragment  and  the  bone 
from  which  it  was  taken  in 
determining  the  success  of 
the  operation.  In  trans- 
planting fragments  of  con- 
siderable size,  every  effort 
should  be  made  to  preserve 
at  least  a  slight  vascular 
supply ;  this,  however,  is 
not  essential  in  filling  in 
gaps  of  even  large  extent 
by  smaller  bone  fragments.  Preservation  of  the  periosteum  is  very 
important,  as  the  bone  chips  and  vivified  ends  of  the  fragments 
should  be  furnished  with  a  vascular  bone-producing  covering. 

Vicious  Union. — Vicious  union  can  not  always  be  prevented, 
even  by  the  most  careful  and  painstaking  treatment,  as  the  injuries 
of  the  soft  tissues  do  not  always  permit  of  the  most  efficient  mechani- 
cal measures  in  securing  complete  reduction  and  perfect  retention. 
It  is  in  such  cases  that  the  physician  should  resort  to  early  efforts 
in  correcting  the  malposition  as  soon  as  the   condition  of  the  soft 


Fig.  264. — Vicious  union  of  fracture  of  both 
bones  of  the  forearm.  Great  overlapping  of 
fragments  of  the  radius  and  marked  deviation 
toward  the  radial  side. 


SPECIAL    FRACTURES.  4II 

tissues  warrants  such  an  attempt.  Manual  brisement  force  often 
succeeds  in  correcting  the  deformity  in  from  four  to  eight  weeks  after 
the  injury  occurred,  and  in  delayed  union  several  months  after  the 
accident.  In  vicious  union  with  the  fragments  united  by  a  bony 
callus,  more  force  is  required,  and  the  osteoclast  must  be  substituted 
for  manual  force.  If  the  osteoclast  can  not  be  used,  owing  to  the 
seat  of  the  fracture  or  to  the  uncertainty  as  to  where  the  fracture 
will  take  place,  the  continuity  of  the  bone  is  destroyed  with  a  chisel 
used  through  an  open  incision,  and  that  section  is  made  that  offers 
the  best  local  condition  for  the  correction  of  the  deformity  by  the 
subsequent  treatment  of  the  recent  compound  fracture.  A  linear 
osteotomy  will  suffice  in  some  cases,  while  others  require  a  wedge- 
shaped  excision  of  bone,  with  the  base  of  the  wedge  corresponding 
with  the  convex  surface  of  the  angle.  In  some  cases  subcutaneous 
drilling,  carried  to  the  extent  of  weakening  the  bone  sufficiently  to 
yield  to  manual  force,  or  the  osteoclast  at  the  desired  point,  will 
constitute  the  safest  and  most  advisable  procedure  in  correcting  the 
vicious  union. 


CHAPTER  X. 

SPECIAL  FRACTURES. 

I  HAVE  made  an  effort  to  describe,  somewhat  in  detail,  the  general 
principles  that  should  govern  the  treatment  of  fractures,  upon  which 
the  physician  must  rely  largely  in  the  management  of  special  frac- 
tures. Each  case  must  be  studied  on  its  own  merits,  in  order  intel- 
ligently to  meet  special  indications.  It  is  my  purpose  in  this  section 
to  consider  only  the  fractures  that  present  the  greatest  difficulties  to 
accepted  methods  of  treatment,  and  that  have  so  often  been  followed 
by  vicious  union,  nonunion,  and  unsatisfactory  functional  results. 
Preeminent  among  these  are  fractures  of  the  neck  of  the  femur  and 
Colles'  fracture  of  the  lower  end  of  the  radius.  The  latter  fracture 
is  so  frequent,  and  the  results  are  so  very  unsatisfactory  when  not 
recognized  or  when  improperly  treated,  that  a  repetition  of  what 
has  already  been  said  with  special  reference  to  this  fracture  can 
not  be  out  of  place. 

Fractures  of  the  neck  of  the  femur  are  always  dreaded  by  all 
physicians,  because  the  results  are  such  as  often  to  cast  a  reflection 
on  the  treatment  pursued,  besides  being  a  source  of  great  disap- 
pointment to  the  patient.  I  have  for  a  long  time  entertained  very 
decided  views  regarding  the  possibility  of  more  frequently  obtain- 
ing repair  by  bony  callus  in  nonimpacted  intracapsular  fractures 
by  more  energetic  treatment — a  treatment  calculated  to  bring  into 
action  the  .same  principles  that  should  govern  the  treatment  of 
fracture  in   any  other  locality — than   by  abandoning  the  idea  of 


412  SPECIAL    FRACTURES. 

making  an  attempt  to  carry  these  principles  into  effect  in  such  cases, 
and  of  adopting  a  treatment  accordingly.  Fractures  of  the  neck 
of  the  femur  and  Colles'  fracture  receive  special  consideration  here 
because  they  serve  as  a  useful  and  instructive  object-lesson  in  illus- 
trating the  difficulties  that  we  encounter  in  the  diagnosis  and  treat- 
ment not  only  of  these  two  fractures,  but  also  of  all  fractures  near 
or  involving  any  of  the  large  joints. 

Fractures  of  the  Neck  of  the  Femur. — The  treatment  of  a 
fracture  of  the  neck  of  the  femur  is  always  a  source  of  anxiety  to 
the  surgeon.  In  many  instances  the  diagnosis  is  attended  by 
unusual  difficulties,  and  not  infrequently  a  fracture  of  this  kind  is 
overlooked,  even  after  what  appears  to  have  been  a  thorough 
examination,  while  at  other  times,  for  want  of  a  correct  diagnosis, 
patients  have  been  submitted  to  a  long  and  debilitating  treatment 
when  no  fracture  existed.  Patients  suffering  frorn  this  injury  are, 
with  few  exceptions,  advanced  in  years  and  liable  to  succumb  to 
complications  incident  to  prolonged  confinement  in  bed.  The 
marantic  changes  in  the  tissues  of  the  aged  and  in  persons  ren- 
dered prematurely  old  by  hereditary  or  acquired  causes  are  known 
to  be  antagonistic  to  a  rapid  repair  of  such  an  injury,  while  at  the 
same  time  the  anatomic  conditions  at  the  seat  of  fracture  are  such 
as  are  well  calculated  to  retard,  if  not  to  prevent,  the  production  of 
callus.  With  few  exceptions  our  surgical  text-books  and  special 
works  on  fractures  continue  to  advance  the  same  ideas  that  have 
been  prevalent  for  centuries  concerning  the  process  of  repair  in 
fractures  of  the  neck  of  the  femur,  and  assert  that  bony  union  is 
only  possible  if  the  line  of  fracture  is  completely,  or  at  least  par- 
tially, outside  of  the  limits  of  the  capsular  ligament.  Teachers 
and  authors  are  so  positive  in  their  assertions  that  if  the  fracture 
is  entirely  intracapsular  a  pseudarthrosis  is  inevitable,  that  many 
cases  of  partly  extracapsular  fractures  have  been  treated  on  the 
expectant  plan,  the  same  as  intracapsular  fracture,  and  only  too 
often  with  the  same  unsatisfactory  result.  The  time  has  come 
when  it  is  no  longer  admissible  to  make  such  a  distinction  in  the 
lecture  room,  in  the  text-books,  or  at  the  bedside.  Experience  and 
experimental  research  have  demonstrated  that  the  proximal  frag- 
ment, in  case  the  line  of  fracture  is  entirely  intracapsular,  does  not 
only  retain  its  vitality,  but  if  placed  in  accurate  contact  with  the 
opposite  fragment,  either  by  impaction  or  by  mechanical  fixation, 
will  take  an  active  part  in  the  production  of  callus. 

In  a  paper  read  at  the  meeting  of  the  American  Surgical  Asso- 
ciation in  1883  I  gave  an  account  of  fifty -four  cases,  collected 
from  different  sources,  of  bony  union  after  intracapsular  fracture  of 
the  neck  of  the  femur,  and  in  most  of  them  the  proofs  in  support 
of  the  assertion  were  so  convincing  that  even  skeptics  on  this 
subject  would  find  it  difficult  to  give  to  them  a  different  interpre- 
tation. In  the  same  paper  were  recorded  the  results  of  my  own 
experimental   work,    undertaken  for  the  special  object  of  demon- 


EXPERIMENTS    IN    OBTAINING    BONY    UNION.  4I3 

strating,  if  possible,  that  bony  union  after  intracapsular  fracture  is 
so  seldom  obtained,  not  so  much  on  account  of  the  anatomic  pecu- 
liarities of  the  parts  involved  in  the  fracture,  as  the  inefficient  efforts 
that  are  resorted  to  in  its  treatment,  owing  to  the  wide-spread 
opinion  that  bony  union  is  not  obtainable  by  any  kind  of  treatment 
of  nonimpacted  intracapsular  fractures.  These  experiments  are 
introduced  here  as  evidence  of  the  results  that  usually  attend  frac- 
tures of  the  neck  of  the  femur  within  the  capsule  treated  by  the 
old  methods,  as  well  as  to  show  that  immediate  and  perfect  re- 
duction and  uninterrupted  retention  will  succeed,  in  many  cases,  in 
securing  union  by  bony  callus  \'ielding  excellent  functional  results. 
Experiments  on  Animals  Made  for  the  Purpose  of  Proving 
the  Possibility  of  Obtaining  Bony  Union  by  Immediate  Reduc= 
tion  and  Perfect  Retention. — These  experiments  were  made  with 
a  view  to  obtaining  reliable  information  concerning  the  following 
questions  : 

1.  What  is  the  mode  of  repair  after  nonimpacted  intracapsular 
fracture  of  the  neck  of  the  femur? 

2.  What  becomes  of  a  bone  or  metallic  nail  when  driven  into 
the  neck  of  the  femur  and  j-etained  permanently  ? 

3.  What  is  the  effect  of  such  nails  upon  the  adjacent  bone 
tissue  ? 

4.  Can  we,  in  cases  of  intracapsular  fractures  of  the  neck  of  the 
femur,  by  immediate  or  direct  measures,  as  by  nailing  the  fragments 
together,  obtain  such  accurate  coaptation  and  retention  as  to  secure 
union  by  bone  ? 

A  great  many  difficulties  were  encountered  in  performing  these 
experiments,  preeminent  among  them  being  shortness  of  the  femoral 
neck  and  difficulty  in  carrying  out  the  aseptic  precautions  and  in 
providing  additional  means  for  securing  immobility  of  the  fractured 
bone.  The  operation  was  made  painless  by  injecting  morphin  or 
by  general  anesthesia  with  ether.  The  animals  used  were  cats, 
dogs,  and  rabbits,  embracing,  in  all,  thirty-three  experiments  upon 
thirty  animals. 

In  the  first  thirteen  operations  the  capsule  of  the  hip-joint  was 
exposed  by  a  small  posterior  incision,  and  the  neck  was  rendered 
more  accessible  by  forcibly  rotating  the  thigh  inward  ;  the  bone 
was  perforated  a  sufficient  number  of  times  with  a  small  drill  close 
to  the  head,  and  usually  fractured  by  forcible  abduction  and  rota- 
tion outward  of  the  limb.  The  fracture,  as  a  rule,  took  place  with 
a  di.stinct  snap,  and  was  followed  by  all  the  characteristic  symptoms 
of  fracture  through  the  neck — preternatural  mobility,  shortening, 
and  crepitus.  Tiic  incision  was  clo.sed  with  catgut  sutures,  and  the 
wound  covered  with  iodoform  and  salicylated  cotton.  In  all  these 
ca.scs  the  fractured  bone  was  replaced  as  nearly  as  possible  in  the 
normal  po.sition,  and  a  plaster- of- Paris  dressing  applied,  which  in- 
cluded the  pelvis  and  both  extremities.  Two  of  these  animals  died 
of  pyemia,  and  in  not  a  .single  instance  out  of  the  whole  number 


414  SPECIAL    FRACTURES. 

could  be  found,  at  the  postmortem  examination,  the  slightest  attempt 
at  bony  union.  In  one  instance,  that  of  a  young  Newfoundland  dog, 
the  hip-joint  presented  evidences  of  severe  inflammation  without 
suppuration  ;  the  head  of  the  femur,  having  necrosed,  was  found 
completely  detached  in  the  acetabulum.  In  some  cases  ligamen- 
tous union  had  taken  place,  while  in  others  the  fractured  surfaces 
were  covered  with  healthy  granulations.  In  all  the  specimens  the 
lower  fragment  had  become  shortened.  Having  satisfied  myself 
that  the  antiseptic  treatment  could  not  be  followed  with  sufficient 
accuracy  in  these  cases  to  protect  the  animals  against  infection,  it 
was  decided  to  fracture  the  neck  subcutaneously.  In  the  next  six 
cases,  after  shaving  and  disinfecting  the  hip  and  rotating  the  thigh 
inward  and  sliding  the  skin  forward,  a  puncture  was  made  down  to 
the  neck  of  the  femur  from  behind  with  a  narrow  tenotome,  and 
a  drill  being  inserted  into  the  passage  made,  the  neck  was  divided 
and  fractured  as  before.  The  skin  retracting  made  the  operation 
entirely  subcutaneous.  A  plaster-of- Paris  dressing  was  applied  in 
the  same  manner  as  in  the  first  series  of  experiments.  No  inflam- 
mation or  febrile  reaction  followed  these  operations,  and  the  post- 
mortem examinations  showed  evidence  of  ligamentous  repair.  In 
the  absence  of  bony  union  the  functional  result  in  several  cases 
appeared  remarkable.  With  few  exceptions  all  the  fractures  pro- 
duced so  far  were  proved  at  the  autopsy  to  be  purely  intracapsular. 

In  experiment  No.  21  the  neck  was  fractured  subcutaneously 
and  no  retaining  dressing  applied.  The  animal  was  killed  five 
weeks  after  operation,  and  an  examination  of  the  hip-joint  showed 
that  a  firm  and  short  ligament  connected  the  fragments  within  the 
capsule.  After  the  first  three  weeks  little  or  no  lameness  could  be 
detected. 

Having  failed  in  all  cases  so  far  in  obtaining  union  by  bone,  it 
was  determined  to  change  the  treatment  and  resort  to  immediate 
reduction  and  fixation  of  the  fragments  by  nailing.  The  fracture 
was  produced  subcutaneously  in  the  same  way  as  in  the  preceding 
series  of  cases,  and,  after  replacing  the  limb  in  its  natural  position 
and  sliding  the  opening  in  the  skin  to  a  point  corresponding  with 
the  center  of  the  base  of  the  femoral  neck,  the  drill  was  introduced 
and  a  perforation  made  in  the  direction  of  the  center  of  the  femoral 
neck.  An  aseptic  wire  nail  or  bone  peg  of  proper  length  was  then 
driven  into  the  perforation  made  by  the  drill,  so  that  the  outer  ex- 
tremity of  the  nail  should  not  project  beyond  the  surface  of  the 
bone,  while  the  opposite  end  fixed  the  detached  head  of  the  femur. 
The  first  two  animals  progressed  very  favorably  after  the  operation 
and  appeared  to  suffer  but  little  pain,  but,  unfortunately,  escaped 
before  an  examination  could  be  made  to  ascertain  the  result. 

Experiment  No.  2^. — Young  cat ;  fractured  the  right  femoral 
neck  subcutaneously,  and  nailed  the  fragments  with  a  bone  nail. 
Animal  killed  ten  weeks  after  operation.  Neck  of  femur  almost 
entirely  absorbed  ;    capsular  ligament  thickened  ;    vertical  section 


EXPERIMENTS    IN    OBTAINING    BONY    UNION.  415 

through  head,  neck,  and  upper  part  of  the  shaft  shows  that  the 
head  is  ahnost  in  contact  with  the  trochanteric  portion  of  the  femur. 
Posterior  portion  of  neck  shows  Hne  of  fracture  near  the  head  and 
fractured  surfaces  in  close  contact,  but  movable  upon  each  other. 
Anterior  portion  firmly  united  by  a  dense  compact  callus,  the  upper 
fragment  apparently  impacted  into  the  lower  ;  no  trace  of  the  bone 
peg  could  be  found.  The  perforation  in  the  trochanter  major  can 
be  followed  to  a  distance  of  about  two  millimeters.  In  this  specimen 
the  lower  fragment  as  far  as  the  capsular  ligament  appears  to  have 
become  almost  entirely  absorbed,  as  the  upper  fragment  remains 
unchanged  and  is  almost  in  direct  contact  with  the  trochanteric 
portion  of  the  femur.      Ligamentum  teres  normal. 

Experiment  No.  2§. — Adult  cat ;  subcutaneous  fracture  of  neck 
of  right  femur ;  direct  transfixion  of  fragments  with  wire  nail. 
Animal  killed  eighteen  weeks  after  operation.  Fracture  within 
capsule  close  to  the  head ;  fragments  in  close  contact,  slightly 
movable  upon  each  other,  but  united  by  a  very  short  ligament. 
Nail  had  slipped  outward,  and  projected  from  the  trochanteric  sur- 
face about  one-third  of  an  inch,  and  could  be  felt  as  a  sharp  point 
immediately  under  the  skin.  The  projecting  portion  of  the  nail 
is  invested  by  a  firm,  dense,  fibrous  capsule,  while  the  implanted 
portion  is  firmly  and  immovably  fixed  in  the  bone.  Vertical  section 
through  the  head,  neck,  and  trochanteric  portion  shows  that  almost 
the  entire  neck  has  disappeared  by  interstitial  absorption,  the  upper 
fragment  being  nearly  in  contact  with  the  trochanteric  portion. 
The  trochanteric  portion  has  lost  the  greater  part  of  its  cancellated 
structure,  its  interior  being  filled  with  compact  tissue  ;  this  change 
is  conspicuous  more  particularly  in  that  portion  of  the  bone  trav- 
ersed by  the  nail.  Capsular  ligament  thickened  ;  ligamentum  teres 
normal. 

Experiment  No.  26. — Adult,  large  Maltese  cat ;  subcutaneous 
fracture  of  right  femoral  neck  ;  direct  coaptation  of  fragments  with 
wire  nail.  Animal  killed  ten  weeks  after  operation.  Neck  of  femur 
shortened  ;  capsular  ligament  thickened  ;  ligamentum  teres  normal  ; 
vertical  section  through  the  upper  portion  of  the  femur  shows  line 
of  fracture  within  capsule,  with  impaction  of  upper  fragment  into 
lower  ;  fragments  movable  upon  each  other,  but  broken  surfaces  in 
immediate  contact.  A  new  compact  layer  of  bone  was  formed  on 
the  outer  surface  of  the  compacta  in  the  region  of  the  lesser  tro- 
chanter. Nail  firmly  embedded  in  bone  ;  outer  extremity  on  a  level 
with  compact  layer  of  trochanter  major ;  it  is  seen  to  traverse  the 
trochanteric  portion  in  a  backward  direction,  entering  the  cavity  of 
the  hip-joint,  and  being  in  close  contact  with  the  posterior  surface  of 
the  femoral  neck,  its  sharp  point  being  on  a  level  with  the  highest 
point  of  the  head.  No  inflammation  in  the  hip-joint.  During  life 
the  function  of  the  joint  appeared  to  be  perfect.  As  the  point  of 
the  nail  was  firmly  fixed  in  the  capsular  ligament  and  impaction  had 
taken  place   during  the   nailing  process,  immobility  was  tolerably 


41 6  SPECIAL    FRACTURES. 

well  attained,  and  there  is  every  reason  to  believe,  that  bony  union 
would  ultimately  have  taken  place. 

Experiment  No.  2y. — Adult  Maltese  cat ;  subcutaneous  fracture 
of  left  femoral  neck  ;  direct  adjustment  of  fragments  by  bone  nail. 
Cat  died  of  fatty  degeneration  of  liver  and  kidneys  five  weeks  after 
operation.  Vertical  section  through  upper  portion  of  femur  reveals 
line  of  fracture  partly  within  and  partly  without  the  capsule.  No 
union  ;  fragments  in  good  apposition  ;  outer  extremity  of  bone 
nail  beneath  the  compacta  ;  direction  of  nail  downward  and  inward, 
the  point  terminating  a  little  beyond  the  hne  of  fracture  in  the 
neck.  The  saw  has  cut  the  nail  obliquely  at  the  juncture  of  the 
outer  with  the  middle  third.  No  evidences  of  inflammation  or 
repair. 

Experiment  No.  2g. — Adult  cat ;  fractured  neck  of  left  femur 
subcutaneously,  and  used  bone  peg  for  nailing  fragments  together. 
Animal  died  of  pyemia  twelve  days  after  operation.  Hip-joint 
filled  with  pus  ;  fracture  intracapsular  ;  outer  extremity  of  nail  on 
a  level  with  compacta  ;  its  point  was  in  the  cavity  of  the  joint,  on 
a  level  with  the  foveola  of  the  head.  A  piece  of  the  posterior 
portion  of  the  head  is  split  off,  an  accident  that  occurred  either  in 
the  use  of  the  drill  or  in  driving  in  the  nail. 

Experiment  No.  jo. — Adult  cat ;  subcutaneous  fracture  of  right 
femoral  neck  and  direct  transfixion  of  fragments  by  wire  nail. 
Animal  died,  four  weeks  after  operation,  of  pneumonia.  No  in- 
flammation of  joint  ;  fracture  intracapsular ;  fragments  slightly 
separated,  but  well  transfixed  by  nail ;  no  callus. 

Experiment  No.  j2. — Young  cat  ;  subcutaneous  fracture  of  neck 
of  right  femur  ;  direct  fixation  of  fragments  with  bone  peg.  Ani- 
mal killed  four  months  after  operation.  During  life,  function  of 
the  joint  was  perfect ;  vertical  section  through  the  head,  neck,  and 
upper  portion  of  shaft  shows  that  the  line  of  fracture  must  have 
been  entirely  within  the  capsule,  as  no  thickening  of  bone  or  of 
ligament  could  be  seen ;  capsular  ligament  normal.  Accurate 
measurement  shows  only  an  appreciable  shortening  of  neck  ;  com- 
pact tissue  within  neck  more  abundant  than  in  the  opposite  bone. 
Spongiosa  restored  to  nearly  its  natural  perfection.  No  trace  of 
track  of  perforation  or  bone  nail. 

In  no  case  was  crepitation  felt  more  distinctly  than  in  this  case, 
and  the  sudden  giving  way  of  the  bone  the  moment  it  was  fractured 
was  well  marked  and  heard  by  several  witnesses,  and  as  the  post- 
mortem examination  shows  a  perfect  restoration  of  the  continuity 
of  the  bone,  it  is  certain  that  this  case  represents  a  typical  and 
perfect  recovery  through  union  by  bone  after  intracapsular  fracture 
of  the  neck  of  the  femur. 

In  all  cases,  twenty-one  in  number,  where  no  direct  means  of 
fixation  were  used,  there  was  not  the  slightest  evidence  of  bony 
union  ;  the  best  result  attained  was  a  short  ligamentous  band.  In 
experiment   No.    21    no   retention  dressing  was   applied,    and  the 


EXPERIMENTS    IX    OBTAINING    BONY    UNION.  4I7 

result  was  equally  as  good  as,  if  not  better  than,  in  the  cases  where 
the  plaster-of-Paris  dressing  was  used. 

In  all  these  cases  the  tendency  to  shortening  was  not  so  well 
marked  as  in  man,  while  eversion  occurred  seldom,  and  only  to  a 
slight  degree. 

The  weight  of  the  limb  evidently  counteracted  muscular  action, 
while  the  conditions  that  produce  eversion  in  man  are  absent  in 
animals.  The  results  obtained  by  immediate  transfixion  of  the 
fragments  stand  in  direct  contrast  to  those  treated  by  external  fixa- 
tion. Bony  union,  or  union  by  short  ligament,  was  the  rule  ;  non- 
union, the  exception. 

These  experiments  would  also  tend  to  prove  that  aseptic 
metallic  nails,  when  implanted  subcutaneously  into  living  bone, 
remain  firmly  in  its  substance  for  an  indefinite  period  of  time  with- 
out giving  rise  to  suppuration,  and  from  one  of  the  experiments  it 
will  be  seen  that  the  point  of  the  nail  was  within  the  cavity  of  the 
joint  for  many  weeks  without  materially  interfering  with  the  nor- 
mal function  of  the  joint,  or  producing  more  than  a  slight  syno- 
vitis. 

Ivory  and  bone  nails,  if  driven  into  li\ing  bone,  produce  an 
osteoplastic  process,  and  are,  on  this  account,  not  only  useful  in 
the  treatment  of  pseudarthrosis,  but  are  equally  efficient  in 
accelerating  the  reparative  process  in  recent  fractures.  Aseptic 
bone  and  ivor}'  nails  in  aseptic  tissues  are  completely  absorbed, 
the  time  required  for  absorption  depending  upon  the  vascularity  of 
the  tissues  that  are  in  immediate  contact  with  the  nail. 

According  to  Gurlt,  the  time  required  for  bony  union  is  propor- 
tionate to  the  diameter  of  the  fractured  bone,  being  much  shorter  in 
case  of  slender  bones  as  compared  with  those  of  greater  diameter.  It 
appears  that  the  shortest  time  in  which  the  slender  neck  of  the  femur 
in  cats  unites  by  bone  is  at  least  two  months  ;  hence  it  is  reason- 
able to  assume  that  in  man  the  time  required  for  bony  consolidation 
of  fracture  of  the  femoral  neck  must  be  at  least  from  one  hundred 
to  one  hundred  and  twenty  days.  As  in  two  of  the  specimens 
well-marked  impaction  occurred  during  the  nailing  process,  the 
question  arises  whether  the  same  desirable  conditions  could  not  be 
obtained  in  man  by  using  sufficient  lateral  pressure  at  the  time  direct 
coaptation  is  attempted  ;  in  other  words,  would  it  not  be  prudent  to 
use  sufficient  pressure  to  produce  interlocking  of  the  fragments  or 
even  artificial  imj^action  ?  Interstitial  absorption,  as  the  consequence 
of  osteoporosis,  takes  place  to  a  greater  or  less  extent  in  every 
ca.se  of  fracture  through  the  femoral  neck,  and  precedes  and 
accompanies  the  reparative  proce.ss.  In  all  cases  of  bony  union 
the  posterior  attachment  of  the  cervical  portion  of  the  capsular 
ligament  was  dis[)laced  outward,  an  occurrence  that  can  only  be 
explained  satisfactorily  by  assuming  that  during  the  osteoporotic 
process  the  periosteal  investment  of  the  femoral  neck  is  loo.sened 
and  transplanted  toward  the  femoral  shaft,  carrying  with  it  the 
27 


41 8  SPECIAL    FRACTURES. 

femoral  insertion  of  the  capsular  ligament.  These  experiments 
also  illustrate  the  difficult)^  of  transfixing  the  upper  fragment-in  the 
process  of  nailing,  a  circumstance  largely  due  to  the  diminutive  size 
of  the  bone,  the  incomplete  anesthesia,  and  the  want  of  fixation  of 
the  parts  in  their  relative  normal  positions  previous  to  the  operation. 

Specimens  of  Bony  Union  after  Intracapsular  Fracture  of  the 
Neck  of  the  Femur. — As  the  specimens  representing  bony  union 
after  intracapsular  fracture  of  the  neck  of  the  femur  are  still  few,  and 
the  possibility  of  such  a  method  of  repair  is  still  a  disputed  question, 
I  made  a  ver\*  thorough  search  of  the  literature  on  this  subject,  and 
was  able  to  find  only  fifty -four  well-authenticated  specimens  of  this 
kind.  In  addition  to  these  I  desire  to  place  on  record  another  case 
that  came  under  my  own  personal  observation. 

Bony  Union  after  Intracapsular  Fracture. — The  patient  was 
a  female,  aged  sevent}'-five  years,  who  came  under  m}'  care  as  a 
hospital  patient.  She  was  in  good  health  at  the  time  of  the  acci- 
dent, hence  there  can  be  no  possibilit}^  that  the  extensive  changes 
in  the  neck  of  the  femur  were  the  result  of  senile  coxitis  or  inter- 
stitial absorption.  The  fracture  was  produced  b}*  direct  violence  by 
a  fall  upon  the  greater  trochanter.  Fractures  of  the  neck  produced 
in  this  manner  are  ver}'  apt  to  be  impacted.  Loss  of  function  was 
complete  immediately  after  the  injury,  and  remained  so  for  several 
months.  The  patient  suffered  great  pain  in  the  groin  and  the 
region  of  the  trochanter  minor,  a  symptom  that  is  always  indicative 
of  injury  within  the  capsular  ligament.  For  the  purpose  of  exclud- 
ing asymmetr}^  of  the  bones,  all  the  long  bones  of  both  legs  were 
measured  separately,  and  on  comparing  the  measurements,  the 
injured  limb  was  found  one-half  of  an  inch  shortened.  The  limb 
was  strongly  everted.  Gentle  traction  had  no  elTect  on  the  length 
of  the  limb.  On  comparing  the  movements  of  the  trochanter  major 
on  both  sides  b\'  rotating  the  limbs,  it  was  found  that  the  neck  of 
the  femur  on  the  affected  side  was  perceptibly  shorter.  No  crepita- 
tion could  be  felt.  As  the  impaction  appeared  to  be  firm,  no  treat- 
ment was  employed  except  rest  in  bed,  on  a  smooth,  even  mattress, 
with  sand-bags  on  each  side  of  the  limb  for  support.  In  this  position 
the  patient  remained  for  three  months  ;  at  the  expiration  of  this 
time  she  was  allowed  to  walk  on  crutches.  Three  weeks  after  the 
injury  the  shortening  gradually  increased  until  it  reached  an  inch 
and  a  half  The  secondar}'  shortening  evidently  was  the  result  of 
a  loosening  of  the  impaction  by  the  osteoporosis  and  absorption  of 
some  of  the  spongiosa  of  the  neck  of  the  femur  ;  it  might  have 
been  prevented  by  more  efficient  fixation  of  the  fragments  by  lateral 
pressure,  combined  with  immobilization  of  the  pelvis  and  limb. 
The  patient  eventually  was  able  to  walk  quite  well  with  the  aid  of 
a  cane.  Two  years  after  the  accident  she  died  of  pneumonia. 
Autopsy  revealed  the  following  conditions  of  the  joint  and  neck  of 
the  femur  : 

"  The  capsule   of  the  joint,   especially  the  upper  portion,  was 


BON"V    UNION    AFTER    INTRACAPSULAR    FRACTURE. 


419 


Fig.  265. — Bony  union  after  intracapsular  fracture  ('posterior 
view)  :  a,  Capsular  ligament. 


thickened  and  firm,  and  bridges  of  fibrous  bands  connected  the 
hne  of  fracture  with  the  anterior  portion  of  the  hgament.  On  the 
anterior  surface  of 
the  neck  the  direc- 
tion of  the  fracture 
could  be  clearly 
traced  from  below 
upward  and  from 
within  outward,  but 
not  extending  be- 
yond the  insertion 
of  the  capsular 
ligament.  The  line 
of  fracture  is  ele- 
vated and  presents 
a  serrated  appear- 
ance. Posteriorly 
the  head  of  the 
bone  was  in  close 
proximit}-  to  the 
posterior  intertro- 
chanteric ridge.  A  slight  depression  on  the  articular  cartilage 
marked  the  point  of  contact  with  the  inner  surface  of  the  capsular 

ligament.        Impaction 
(^^  n  had      evidently     taken 

place  at  the  expense 
of  the  posterior  com- 
pact portion  of  the 
neck.  A  portion  of 
Adams'  arch,  which 
had  been  impacted  into 
the  lower  fragment, 
could  be  distinctly  seen 
in  the  spongiosa  in 
making  a  vertical  sec- 
tion. A  vertical  sec- 
tion through  the  neck, 
head,  and  trochanter 
revealed  a  white  line 
of  verj'  compact  bone 
traversing  the  cancel- 
lated tissue  of  the  neck 
near  the  shaft  in  an  ob- 
lique direction,  corres- 
ponding to  the  line  of 
fracture  on  the  anterior 
surface  of  the  neck.  The  anterior  half  of  the  specimen  has  been 
submitted  to  the  boiling  test  without  affecting  the  union  of  the 


^at 


7 


..^j.. 


.^f 


Fig.  266. — Bony  union  after  intracapsular  fracture  (ver- 
tical section)  :  a.  Compact  plate  of  bone. 


420  SPECIAL    FRACTURES. 

fragments  ;  hence  there  can  be  no  doubt  as  to  the  union  by  bone. 
The  bone  outside  of  the  capsular  hgament  presents  no  sign  of  callus 
or  any  other  evidences  of  injury  or  disease." 

This  specimen,  as  well  as  the  specimens  obtained  from  the 
experiments,  are  in  the  Army  Medical  Museum. 

Classification  of  Fractures  of  the  Neck  of  the  Femur. — Since 
the  teachings  of  Sir  Astley  Cooper  on  this  subject,  it  has  been 
customary  to  classify  fractures  of  the  cervix  femoris,  according  to 
the  relative  position  the  capsular  ligament  bears  to  the  line  of  frac- 
ture, into  the  intracapsular  and  extracapsular  fractures,  to  which 
has  been  added  a  third  variety,  fractures  partly  within  and  partly 
without  the  capsular  ligament.  The  mixed  variety  has  given  rise 
to  a  great  deal  of  confusion,  as  some  have  included  it  among  intra- 
capsular, others  among  extracapsular,  fractures.  Since  it  has  been 
ascertained  that  many  of  the  fractures  of  the  neck  of  the  femur 
are  impacted,  those  who  have  placed  great  prognostic  and  thera- 
peutic importance  upon  this  condition  have  made  impaction  the 
basis  for  a  new  classification — impacted  and  nonimpacted  fractures 
of  the  neck  of  the  femur.  Among  those  who  have  supported  this 
classification  may  be  mentioned  Cloquet,Gosselin,  Duplay,  Bigelow, 
Bryant,  Hueter,  and  Lossen. 

The  distinction  between  impacted  and  nonimpacted  fractures  is 
important  in  a  clinical,  diagnostic,  prognostic,  and  therapeutic  sense, 
while  the  division  into  intracapsular  and  extracapsular  fractures  has 
a  very  important  pathologic  significance.  Fractures  of  the  neck  of 
the  femur  with  impaction  will  unite  by  bony  union,  irrespective  of 
the  location  of  the  line  of  fracture,  provided  the  impaction  is  main- 
tained for  a  sufficient  length  of  time.  Fractures,  impacted  or  non- 
impacted,  outside  of  the  capsular  ligament,  will  unite  in  the  same 
manner  as  fractures  in  any  other  locality,  if  the  fractured  ends  are 
kept  in  apposition  and  are  immobilized  for  the  necessary  length  of 
time.  Fractures  at  the  narrow  part  of  the  neck  and  entirely  within 
the  capsule  can  unite  only  by  bone  if  the  penetration  is  such  as  to 
secure  apposition  for  a  number  of  weeks,  or  if  the  same  degree  of 
apposition  and  immobilization  is  effected  by  surgical  procedures. 
The  frequency  with  which  impaction  occurs  in  the  femoral  neck 
and  the  important  part  it  performs  in  the  reparative  process  entitle 
it  to  a  permanent  place  as  a  basis  for  classification. 

When  we  are  able  to  diagnosticate  the  existence  of  an  impacted 
fracture  of  the  neck  of  the  femur,  all  efforts  to  locate  the  exact 
seat  of  fracture  are  worse  than  useless,  as  it  could  have  no  in- 
fluence in  selecting  therapeutic  measures,  and  might  eventuate  disas- 
trously by  abolishing  the  most  favorable  conditions  for  a  fortu- 
nate issue.  If  we  adopt  the  proposition  that  fractures  of  the 
femoral  neck  with  penetration  can,  and  often  do,  unite  by  bone, 
irrespective  of  their  relative  position  to  the  capsular  ligament, 
then  the  distinction  between  fractures  within  and  fractures  without 
the  capsular  ligament  can  only  find  a  practical  application  in  the 


FRACTURES    OF    THE    NECK    OF    THE    FEMUR.  42 1 

examination  of  specimens  to  prove  or  disprove  the  correctness 
of  the  proposition.  This  is  the  more  true  as,  i)i  vivo,  all 
known  diagnostic  means  have  proved  unreliable  in  locating  the 
exact  point  of  fracture.  The  sooner  the  profession  can  be  con- 
vinced that  intracapsular  fractures  also  unite  by  bony  union  under 
certain  favorable  conditions,  the  better  will  it  be  to  abandon  the 
old  classification,  which  has  proved  to  be  incorrect  anatomically 
and  unwarranted  by  pathologic  facts.  Practicall}-,  then,  it  is  always 
important  to  ascertain  the  presence  of  impaction,  and  not  to  inter- 
fere with  it  when  found  ;  theoretically,  and  for  the  purpose  of 
adopting  therapeutic  measures,  it  is  desirable  in  nonimpacted  frac- 
tures to  locate,  as  nearl)'  as  possible,  the  seat  of  fracture  without 
inflicting  unnecessary  violence. 

In  the  light  of  recent  anatomic  investigation  and  pathologic 
research,  and  for  the  purpose  of  avoiding  unnecessary  confusion, 
it  would  be  advisable  to  limit  the  term  intracapsular  to  all  fractures 
that  do  not  extend  be}-ond  the  insertion  of  the  capsular  ligament, 
and  include  among  the  extracapsular  fractures  the  so-called  mixed 
and  purely  extracapsular  fractures.  Remembering  the  attachment 
of  the  anterior  portion  of  the  capsular  ligament,  we  should  naturally 
infer  that  pureh*  extracapsular  fractures  without  further  injury  to 
the  shaft  of  the  femur,  if  possible  at  all,  must  be  exceedingly  rare. 
The  greatest  number  of  extracapsular  fractures,  as  described  in  our 
text-books,  belong  to  the  mixed  variety  :  intracapsular  in  front, 
extracapsular  behind.  In  speaking  of  extracapsular  fractures 
R.  \V.  Smith  says  :  "  All  extracapsular  fractures  are,  in  the  first 
instance,  also  impacted  fractures,  and  all  impacted  fractures  are 
necessarily  accompanied  by  a  fracture  traversing  some  part  of  the 
trochanteric  region.  I  have  omitted  no  opportunity  of  investigating 
this  point,  and  have  now  examined,  here  and  elsewhere,  upward 
of  one  hundred  specimens  of  the  extracapsular  fracture,  and  have 
found  in  all,  without  a  single  exception,  a  second  fracture  travers- 
ing some  portion  of  the  intertrochanteric  space." 

In  commenting  upon  this  paper  A.  C.  Post  suggested  the  substi- 
tution of  the  terms  intracervical  and  extracervical  for  intracapsular 
and  extracapsular,  the  latter  designation  to  indicate  an  impacted  frac- 
ture at  the  base  of  the  neck  with  more  or  less  injury  of  the  femoral 
shaft.  As  under  this  classification  intracervical  fractures  would 
include  intracapsular  and  mixed  fractures,  and  the  term  extracer- 
vical would  imply  the  existence  of  a  fracture  rather  beyond  than 
in  the  cervix  itself,  these  terms  do  not  convey  sufficiently  accurate 
anatomicopathologic  precision  to  recommend  themselves  for  general 
adoption,  although  they  are  full  of  practical  .significance.  Inas- 
much as  the  principal  object  in  writing  this  section  is  to  prove  that 
bony  union  after  intracapsular  fractures  can  take  i:)lace,  the  terms 
intracapsular  and  extracapsular  are  retained,  u.scd  in  the  sense 
previously  suggested. 

Relative  Number  of  Intracapsular  and   Extracapsular   Frac- 


422  SPECIAL    FRACTURES. 

tures. — The  inability  accurately  to  locate  the  fracture  during  life 
and  the  existing  confusion  and  uncertainty  as  to  the  meaning  and 
application  of  the  terms  intracapsular  and  extracapsular  in  the 
description  of  specimens  have  rendered  the  statistics  on  this  point 
unsatisfactory  and  unreliable.  Although  the  cervix  femoris  may 
be  broken  at  any  point  between  the  head  of  the  femur  and  the 
intertrochanteric  ridges,  there  are  certain  points  where  it  is  more 
liable  to  give  way.  The  exact  location  of  the  fracture  is  deter- 
mined to  a  great  extent  by  the  seat  and  degree  of  senile  osteo- 
porosis and  the  direction  of  the  fracturing  force.  Senile  osteo- 
porosis, as  we  have  seen,  begins  in  the  spongiosa  and  reaches  its 
maximum  degree  soonest  at  the  contracted  portion  of  the  neck  ; 
hence  fracture  nearest  the  head  is  most  likely  to  take  place  in 
decrepit  old  people.  Fractures  at  this  point  are  exceedingly  rare 
in  persons  less  than  fifty  years  of  age,  only  a  very  few  well- 
authenticated  cases  being  on  record.  Rodet,  in  a  series  of  ex- 
periments on  the  femur  and  on  plaster-of- Paris  casts  of  the  upper 
extremity  of  this  bone,  has  demonstrated  the  important  fact  that 
the  situation  and  direction  of  a  fracture  of  the  neck  of  the  femur 
may  be  predicted  to  almost  a  certainty  by  a  knowledge  of  the 
direction  in  which  the  force  was  applied.  Thus,  a  force  acting 
vertically  will  produce  an  oblique  intracapsular  fracture  ;  a  force 
acting  from  before  backward,  a  transverse  intracapsular  fracture  ; 
one  from  behind  forward,  a  fracture  partly  within  and  partly 
without  the  capsule  ;  and  a  force  applied  transversely,  a  fracture 
entirely  without  the  capsule.  Clinical  evidence  has  repeatedly  veri- 
fied the  correctness  of  these  observations.  The  traction  fractures 
described  by  Linhart,  Riedinger,  and  Hueter,  from  the  powerful 
traction  of  the  iliofemoral  ligament  when  the  thigh  is  overextended 
and  adducted,  invariably  fall  outside  of  the  limits  of  the  capsule. 

Bonnet  believed  that  the  line  of  fracture  was  almost  always 
without  the  capsule,  and  Nelaton  contended  that  in  the  great 
majority  of  cases  he  made  the  same  observation  ;  while  many  equally 
competent  authors,  among  them  Sir  Astley  Cooper,  Ashhurst,  and 
Druitt,  claim  that  intracapsular  fracture  occurs  more  frequently  in 
persons  above  fifty  years  of  age.  Of  12  specimens  examined  in 
the  museum  of  St.  Bartholomew's  Hospital  by  Stanley,  6  were  sup- 
posed to  be  intracapsular  and  6  extracapsular.  Malgaigne  exam- 
ined 103  specimens  from  different  sources  to  determine  the  relative 
frequency  of  these  fractures,  and  found  that  61  belonged  to  the 
intracapsular,  against  42  of  the  extracapsular,  variety. 

M.  Mercier,  at  Bicetre,  found,  in  8  autopsies,  3  intracapsular  to 
4  extracapsular  fractures,  and  i  below  the  trochanters  ;  while  Mal- 
gaigne himself,  in  the  same  hospital,  found,  in  8  other  autopsies,  i 
fracture  below  the  trochanters,  5  within  the  capsule,  and  only  i 
outside  of  it.  Stimson  made  a  postmortem  examination  in  6  cases, 
and  ascertained  that  in  2  of  them  the  fracture  was  purely  intracapsu- 
lar, and  in  4  it  was  at  the  junction  of  the  neck  with  the  shaft. 


INCOMPLETE  FRACTURES  OF  THE  NECK  OF  THE  FEMUR.   423 

Heppner  gives  a  description  of  5  cases  of  impacted  fractures  of 
the  neck  of  the  femur,  of  which  number  3  were  extracapsular  and 
2  intracapsular.  Of  20  specimens  of  fracture  of  the  neck  of  the 
femur  in  the  Museum  of  the  College  of  Physicians,  Philadelphia, 
and  the  University  of  Pennsylvania  examined  by  Agnevv,  10  were 
within  and  13  without  the  capsular  ligament.  Mussey's  collection 
contains  12  specimens  of  fracture  of  the  neck  without  the  capsule 
and  10  within. 

The  foregoing  statistics  embrace  185  postmortem  specimens,  of 
which  number  99  were  fractures  w^ithin  and  86  without  the  capsular 
ligament,  figures  which  would  tend  to  prove  that  intracapsular  frac- 
tures are  more  frequent  than  fractures  without  the  capsule.  It 
must,  however,  be  remembered  that  many  of  these  specimens  were 
collected  for  a  special  purpose,  and  on  that  account  the  numbers 
do  not  represent  the  true  proportion  as  it  actually  exists.  If  the 
statistics  obtained  by  the  examination  of  postmortem  specimens 
are  not  reliable  in  ascertaining  the  relative  frequency  with  which 
these  fractures  occur,  the  information  derived  from  clinical  obser- 
vation must  prove  still  less  satisfactory  in  deciding  this  question,  as 
the  symptoms  during  life  are  not  sufficiently  well  marked  to  enable 
the  surgeon  to  locate  the  exact  seat  of  fracture  with  certainty. 

Billroth  refers  to  27  cases  of  fracture  of  the  neck  of  the  femur, 
of  which  number  13  were  diagnosticated  as  intracapsular  and  14  as 
extracapsular.  In  Dr.  Hyde's  table  of  321  cases  of  fracture  of  the 
femur  we  find  that  the  neck  was  involved  3 1  times  ;  these  were 
supposed  to  be  located  14  times  within  and  17  times  without  the 
capsule. 

Hamilton  has  recorded  84  cases  of  fracture  of  the  femoral  neck 
from  his  own  personal  observation  ;  of  these,  40  were  believed  to 
be  without  the  capsule,  and  30  were  believed  to  be  within  ;  the 
remainder  were  undetermined.  The.se  statistics  furnish  128  cases 
with  57  intracapsular  and  71  extracapsular  fractures,  a  majority  in 
favor  of  the  extracapsular  variety. 

Combining  the  figures  from  the  museum  specimens  and  those 
taken  from  bedside  observ^ation,  we  obtain  3 1 3  cases  of  fracture  of 
the  neck  of  the  femur,  of  which  number  156  were  supposed  to  be 
located  within  and  157  without  the  capsular  ligament. 

Incomplete  Fractures  of  the  Neck  of  the  Femur. — The  struc- 
ture of  the  neck  of  the  femur  in  the  aged  furnishes  conditions 
unusually  favorable  for  the  occurrence  of  partial  or  incomplete 
fracture.  Although  this  form  of  fracture  has  received  but  little 
attention  on  the  part  of  surgical  writers,  receiving  at  the  best  only 
brief  mention,  it  would  appear,  from  the  cases  reported  during  the 
last  few  years,  that  the  accident  is  not  so  rare  as  has  been  supposed. 
Colles  was  the  first  to  call  attention  to  this  variety  of  fractures  as  it 
occurs  in  the  neck  of  the  femur,  and  described  three  cases.  J.  B.  S. 
Jack.son,  of  Boston,  described  a  case  of  incomplete  fracture  (fissure), 
the  line  of  fracture  extending  from,the  junction  of  the  upper  border 


424 


SPECIAL    FRACTURES. 


of  the  neck  with  the  head  downward,  to  within  a  quarter  of  an  inch 
of  the  inferior  and  internal  wall  of  the  bone.  Gurlt  mentions  three 
cases.  In  Tournel's  case  the  infraction  occurred  at  the  upper  por- 
tion of  the  base  of  the  neck,  the  Hne  of  fracture  running  from  the 
digital  fossa  downward.  In  the  case  reported  by  P.  W.  King,  the 
line  of  fracture  was  near  the  head  of  the  femur.  A  bridge  of  compact 
tissue  on  the  anterior  and  upper  portion  of  the  neck,  one-third  of 
the  circumference  of  the  compacta,  remained  intact.  The  third 
specimen  described  he  found  in  the  Pathologic  Museum  in  Giessen. 
The  transverse  infraction  affects  the  entire  posterior  half  of  the 
femoral  neck  about  its  middle,  while  the  anterior  wall  is  not  affected. 
The  margins  of  the  fractured  surfaces  are  in  immediate  contact. 

Koenig  describes  two  specimens.  In  the  first  the  line  of  frac- 
ture occurred  on  the  upper  and  posterior  surface  of  the  neck,  near 
the  head,  with  impaction  of  the  cervical  portion  into  the  head,  while 
the  compact  tissue  on  the  anterior   and  inferior  surface   remained 


Fig.  267. — Incomplete  fracture  of  neck  of  femur  (Koenig) 


entire.  In  the  second  specimen  the  line  of  infraction  took  place 
at  the  lower  surface  of  the  neck,  at  the  most  constricted  point,  with 
penetration  of  the  apex  of  Adams'  arch  into  the  interior  of  the  head, 
while  the  upper  portion  of  the  neck  had  yielded  without  being 
broken.  These  two  varieties  Koenig  considers  as  representing 
typical  forms  of  this  fracture,  the  mechanism  of  their  production 
being  the  same  as  in  complete  fractures  of  the  neck.  In  the  first 
variety,  from  the  direction  of  the  impaction  the  limb  is  rotated 
outward,  while  in  the  second  form  the  foot  remains  in  its  natural 
position,  but  the  limb  is  shortened  in  proportion  to  the  depth  of 
the  impaction.  Koenig  is  of  the  opinion  that  many  of  the  cases  of 
complete  recovery  after  supposed  intracapsular  fractures  were  cases 
of  incomplete  fracture  with  impaction. 

At  the  same  meeting  Billroth  reported  two  cases  in  which  he 
made  the  diagnosis  of  incomplete  fracture  during  life  ;  in  both 
instances  recovery  was  perfect.    ^ 


IMPACTED  FRACTURES  OF  THE  NECK  OF  THE  FEMUR. 


425 


Incomplete  fractures  of  the  neck  of  the  femur,  as  well  as  of 
other  bones,  consist  of  a  loss  of  continuity  of  a  certain  number  of 
cancelli  forming  the  substance  of  bone.  It  may  exist  in  every 
degree,  from  a  fracture  almost  complete  to  one  in  which  the  num- 
ber of  severed  cancelli  is  so  small  as  to  elude  detection  by  the 
naked  eye.  The  location  and  direction  of  the  line  of  infraction,  as 
in  complete  fractures,  must  necessarily  vary  according  to  the  direc- 
tion in  which  the 
force  that  produces 
the  fracture  is  ap- 
plied. Stimson 
says  :  "  The  line  of 
fracture  is  trans- 
verse and  upon  the 
concave  side,  and  is 
produced  by  crush- 
ing, not  by  over- 
bending."  Incom- 
plete fractures  are 
repaired  b}'  the  for- 
mation of  inter- 
mediate callus  be- 
tween the  fractured 
surfaces,  which  re- 
stores the  contin- 
uity of  the  bone. 
The  unbroken  por- 
tion of  the  bone  and 
periosteum  serves 
as  a  perfect  splint, 
which  secures  com- 
plete rest  and  ap- 
position until  the 
injury  is  repaired. 
The  deformity  at- 
tending this  frac- 
ture is  necessarily 
slight,  and  as  the 
symptoms  during 
life  are  not  pro- 
nounced, the  diagnosis  must  always  remain  uncertain.  The  cases 
are  most  likely  to  be  mistaken  for  contusion  of  the  hip  ;  hence  we 
should  always  examine  the  severer  injuries  about  the  hip  with 
unusual  care,  and  if  any  doubt  exists,  give  the  patient  the  benefit 
of  the  same,  and  treat  the  case  as  one  of  incomplete  or  complete 
fracture  with  impaction. 

Impacted  Fractures  of  the  Neck  of  the   Femur. — Impaction, 
penetration,  implantation,  and   incuncation  are  synonymous  terms, 


P'ig.  268. — Impacted  fracture  of  the  tibia  with  over- 
ridinjj  of  the  fragments  of  the  fibula.  The  shaft  of  the 
tibia  is  driven  into  the  spongy  tissue  of  the  upper  fragment. 
Illumination  through  plaster-of-Paris  dressing. 


426 


SPECIAL    FRACTURES. 


used  to  desig-nate  a  fracture  when  one  fractured  end  is  driven  into 
the  other,  an  occurrence  that  secures  perfect  coaptation  and  fixation. 
In  some  instances  impaction  is  mutual.  Impaction  may  be  com- 
plete or  incomplete,  according  to  the  tissue  structure  at  the  seat  of 
the  fracture,  or  the  direction  and  intensity  of  the  fracturing  force. 
Impacted  fractures  are  most  frequently  met  in  the  spongy  portions 
of  the  long  bones  and  in  persons  suffering  from  osteoporosis  from 
any  cause. 

These  fractures  have  only  quite  recently  become  the  object  of 
special  investigation,  and  are  at  the  present  time  securing  the  atten- 
tion their  importance  merits.  Robert  was  the  first  to  give  a  good  de- 
scription of  impacted  fracture  of  the  neck  of  the  femur  and  to  explain 
its  mechanism.  He  specified  the  following  conditions  that  must 
present  themselves  in  order  to  permit  penetration.    In  the  first  place, 

the  penetrating  bone  must  have  a  conic 
shape  and  must  be  placed  opposite  a 
spongy  section  of  bone,  and  must  have 
been  broken  off  close  to  the  insertion 
of  the  same.  The  impacting  force  must 
be  applied  in  the  direction  of  the  long 
axis  of  the  incuneated  bone.  All 
these  conditions  are  presented  in  frac- 
tures through  the  neck  of  the  femur. 
Adams  regarded  the  inner  and  lower 
compact  tissue  of  the  neck  of  the  femur 
as  the  principal  feature  of  impaction. 
The  direction  of  the  fracture  through 
the  neck  being  oblique  from  above 
downward,  the  arch  is  fractured  in 
such  a  way  that  the  apex,  sharp  and 
pointed,  is  placed  opposite  the  loosely 
cancellated  tissue  of  the  shaft,  into 
which  it  is  driven  by  the  same  force 
that  fractured  the  bone. 
Streubel  looked  upon  senile  osteoporosis  as  the  main  cause  of 
impaction.  It  is  necessary,  however,  that  the  compacta  of  the 
fractured  neck  should  retain  sufficient  firmness  to  penetrate  the 
bone  without  being  comminuted.  Some  authors  assert  that  im- 
paction follows  fracture  in  this  way  :  that  the  neck  of  the  femur 
gives  way  to  indirect  violence  from  a  fall  upon  the  foot  or  knee, 
the  impaction  following  by  the  patient  falling  upon  the  trochanter. 
Heppner  assumes  that  the  relation  existing  between  the  neck  of 
the  femur  and  the  trochanteric  portion  of  the  femur  is  the  cause 
of  impaction,  and  takes  into  special  consideration  the  spongiosa,  in 
which  he  distinguishes  two  distinct  layers,  the  one  possessing  a 
greater  degree  of  density  than  the  other.  He  believes  fracture  at 
the  base  of  the  neck  with  impaction  is  always  the  result  of  force 
applied  to  the  trochanter  major,  which  expends  itself  at  the  origin 


Fig.    269. — Posterior  impaction   of 
femoral  neck  (Bigelow). 


IMPACTED  FRACTURES  OF  THE  NECK  OF  THE  FEMUR. 


427 


of  the  femoral  brace  and  fractures  the  entire  base  of  the  cervix. 
Aside  from  the  diminution  in  the  obhquity  of  the  cervix  and  the 
presence  of  osteoporosis,  he  finds  another  cause  for  this  fracture  in 
the  general  atrophy  of  the  aged,  rendering  the  trochanter  major 
more  prominent  and  thus  more  directly  exposed  to  external 
violence. 

This  last  assertion,  however,  is  not  in  accord  with  experience, 
as  corpulent  aged  females  furnish  the  largest  number  of  fractures 
of  the  femoral  neck.  Streubel  made  some  experiments  on  cadavers 
to  determine  the  seat  of  fracture  on  the  application  of  direct  and 
indirect  violence.  To  test  the  effect 
of  violence  applied  in  the  axis  of  the 
femur  he  amputated  the  thigh,  and 
applied  the  force  directly  to  the 
sawed  surface  of  the  femur,  and 
succeeded  only  in  one  instance  in 
producing  an  intracapsular  fracture. 
By  applying  the  force  to  the  tro- 
chanter major  he  produced  one  ex- 
tracapsular impacted  fracture,  while 
in  all  other  cases  the  trochanter 
major  was  fractured.  Heppner  re- 
peated these  experiments  with  the 
same  results.  He  then  reversed 
the  direction  of  the  force.  Taking 
a  femur  stripped  of  its  soft  parts, 
and  resting  the  outer  surface  of  the 
trochanter  major  upon  a  table,  he 
struck  the  head  of  the  femur  with 
an  ax,  and  produced,  in  every 
instance,  a  fracture  of  the  neck 
resembling  an  impacted  fracture. 
He  repeated  the  experiment  thirty 
times,  and  in  five  of  the  cases  the 
impaction  was  typical.  From  these 
experiments  he  concluded  that  the 
fracture  is  produced  by  contre-coup,  whether  the  force  is  applied  to 
the  trochanter  major  or  through  the  axis  of  the  femur.  In  regard 
to  impaction  of  intracapsular  fractures,  he  could  find  nothing  in  the 
literature  on  the  subject  of  fractures  of  the  femoral  neck.  Voillemier 
speaks  of  them  at  length,  but  only  for  the  purpose  of  denying  their 
occurrence.  Jiut  inasmuch  as  he  claims  to  have  seen  several  speci- 
mens where  the  end  of  Adams'  arch  was  found  to  terminate  in  the 
interior  of  the  spongy  portion  of  the  head  of  the  femur,  he  contra- 
dicts himself,  as  the  descrijjtion  corresjionds  with  impaction  of 
the  lower  wall  of  the  femoral  arch  into  the  head.  The  question 
at  i.ssue  is  not  the  degree  of  impaction,  but  whether  it  can  secure 
mutual  fixation  of  the  fragments.      In    most  cases  only  the  lower 


Fig.  270. — Impacted  fracture  of 
the  neck  of  the  femur  at  its  base,  ex- 
hibiting a  massive  extra-articular  callus 
(after  Verity). 


428 


SPECIAL    FRACTURES. 


edge  of  the  outer  fragment  is  impacted,  but  the  contrary  may  occur, 
as  is  evident  from  the  description  given  by  Koenig  under  the  head 
of  partial  fractures. 

For  one  of  the  best  contributions  to  our  knowledge  of  impacted 
fractures  of  the  neck  of  the  femur  we  are  indebted  to  Riedinger. 
He  has  studied  this  subject  by  way  of  experiments  and  examination 
of  museum  specimens.  In  speaking  of  intracapsular  fractures  he 
says  that,  as  a  rule,  the  lower,  and  more  particularly  the  posterior, 
wall  of  the  lower  fragment  is  driven  into  the  spongiosa  _  of  the 
head.     As  a  necessary  consequence  of  this  form  of  impaction  the 

head  of  the  fe- 
mur is  depressed 
and  inclines 
backward,  some- 
times to  such  an 
extent  as  to 
come  in  contact 
with  the  poster- 
ior intertrochan- 
teric line.  The 
cortical  portion 
of  the  lower 
fragment  can  of- 
ten be  traced  in- 
to the  interior  of 
the  head  to  a  dis- 
tance of  an  inch. 
At  the  anterior 
line  of  fracture 
the  denticulated 
margins  retain 
so  firm  a  grasp 
as  to  add  materi- 
ally to  the  firm- 
ness of  the  im- 
paction. 

At  the  base  of  the  neck  of  the  femur  the  conditions  for  impac- 
tion are  most  favorable.  If  sufficient  force  is  applied  over  the 
trochanter  major,  the  neck  fractures  in  such  a  way  that  the  femoral 
brace  is  detached  near  its  origin,  and  constitutes  a  sharp  projection, 
which,  when  slightly  dislocated,  is  placed  vis-a-vis  to  the  spongy 
tissue  of  the  outer  fragment,  and  is  implanted  into  the  same  by  the 
fracturing  force.  The  upper  portion  of  the  inner  fragment,  although 
not  possessed  of  a  dense  structure  analogous  to  that  of  the  femoral 
brace,  follows  in  the  penetrating  process  the  more  readily,  as  the 
whole  inner  fragment  is  wedge  shaped.  The  spongiosa  between  the 
cortical  layers  forms  a  somewhat  sharp  projection.  Impaction  of  the 
base  of  the  neck  is  carried  to  its  fullest  extent  in  case  the  fracturing 


\.  i 


Fig.  271. — Same  specimen  as  figure  270  (vertical  section)  : 
a.  Vertical  section  through  head,  neck,  and  upper  part  of  shaft 
of  femur  ;  b,  vertical  section  through  head,  fractured  neck,  and 
upper  part  of  shaft  of  femur  (after  Verity). 


IMPACTED  FRACTURES  OF  THE  NECK  OF  THE  FEMUR. 


429 


force  is  sufficient  to  fracture  also  the  trochanteric  portion  of  the 
femur.  In  such  instances  the  apex  of  the  inner  fragment  splits  the 
shaft  of  the  femur,  sometimes  into  a  number  of  fragments,  and 
presents  itself  on  the  outer  surface  of  the  bone  beneath  the  soft 
parts. 

Figures  270  and  271  represent  a  very  interesting  specimen. 
Ten  days  after  the  accident  the  patient  from  whom  this  specimen  was 
obtained  ran  out  of  his  burning  house  and  received  no  treatment 
thereafter.     The  union  is  very  firm,  but  not  by  bony  callus. 

Mr.  Bryant  has  published  a  table  of  fourteen  cases  of  impacted 
fracture  of  the  neck  of  the  femur,  and  from  an  analytic  study  of 
these  cases  he  draws  the  following  conclusions  : 

"  I.  That  in  all  the  cases  the  injury  to  the  hip-joint  was  com- 
municated   through    the    great 
trochanter. 

"  2.  That  as  a  result  of  the 
injury  there  was  more  or  less 
loss  of  power  in  the  limb  :  in 
some  cases  it  was  complete,  in 
as  many  the  patient  could  rotate 
the  limb  slightly  on  the  couch, 
and  in  two  cases  partial  flexion 
of  the  thigh  could  be  performed. 

"3.  That  in  all  the  cases  im- 
mediate shortening  of  the  injured 
limb  was  the  direct  result  of  the 
accident ;  and  that  this  shorten- 
ing was  about  an  inch  or  less, 
and  it  was  irremediable  by  ex- 
tension. 

"4.  That    the    foot    of    the 
injured     extremity    was     either 
straight   or  slightly  everted,   al- 
though   in    several    cases    this   eversion   was  less    marked  on   the 
injured  than  on  the  sound  side. 

"5.  That  the  great  trochanter  was  placed  nearer  the  median 
line  of  the  body,  and  also  nearer  the  anterior  superior  spinous  pro- 
cess of  the  crest  of  the  ilium  than  on  the  sound  side. 

"6.  That  the  head  of  the  femur  could  be  made  to  rotate 
smoothly  in  the  acetabulum,  and  the  great  trochanter  moved  with 
it. 

"  7.   That  crepitus  was  either  absent  or  indistinct  in  all  cases. 

"8.  That  all  the  cases,  with  one  exception,  occurretl  in  patients 
past  middle  age." 

Bardeleben  maintains  that  in  intracapsular  fractures  longitudinal 
displacement  is  opposed  by  the  untorn  portion  of  the  capsular 
ligament.  In  this  fracture  the  ends  of  the  fragments  are  often 
interlocked   in  such  a  manner  as  to  prevent  dislocation,  and  may 


Fig.  272. — Impacted  fracture  at  the 
base  of  the  femoral  neck,  with  fracture  of 
the  greater  trochanter  (Hoffa). 


430 


SPECIAL    FRACTURES. 


even  enable  the  patient  to  walk  on  the  limb  for  a  few  hours  or  for 
several  days.  The  more  important  elements  in  retaining  the  frag- 
ments are,  however,  the  presence  of  impaction  and  the  untorn  por- 
tions of  the  reflected  capsule,  the  retinacula  of  Weitbrecht. 

S.  D.  Gross  believes  that  impaction  is  rare,  and,  when  present, 
that  it  is  almost  exclusively  extracapsular.  The  distance  of  pene- 
tration varies  from  a  few  lines  to  one-half  or  three-fourths  of  an 
inch. 

Hueter  places  great  stress  on  recognizing  the  presence  of  im- 
paction. He  regards  the  "  Schenkelsporn  "  as  the  most  important 
agent  in  the  process  of  impaction.  Anatomically,  he  distinguishes 
two  varieties  :  either  the  upper  end  of  the  lower  fragment  is  dis- 
placed inward,  so  that  the  termination  of  the  Schenkelsporn  pene- 
trates the  soft  tissues  below  the  upper  fragment,  or  the  lower  frag- 
ment is  displaced  outward  in  such  a  manner  that  the  Schenkelsporn 
is  driven  into  the  spongiosa  of  the  neck. 

Impacted  fractures  are  not  so  frequent  as  nonimpacted  fractures, 
but  they  are  sufficiently  common  to  impart  great  importance  to 
them  in  diagnosis,  prognosis,  and  treatment  of  fractures  of  the  neck 
of  the  femur. 

H.  H.  Smith  believes  that,  in  the  majority  of  cases,  the  neck  of 
the  femur  is  fractured  by  indirect  violence,  impaction  following  sub- 
sequently by  a  fall  upon  the  trochanter  major. 

R.  W.  Smith  says  that  "  all  extracapsular  fractures  are,  in  the 
first  instance,  also  impacted  fractures." 

Robert  was  of  the  opinion  that  fractures  of  the  neck  of  the 
femur  were  nearly  always  impacted,  and  as  such  should  be  dis- 
turbed as  little  as  possible  to  obtain  the  best  results,  as  the  impac- 
tion furnishes  the  best  possible  conditions  for  bony  union  to  take 
place. 

MacNamara  affirms  that  fractures  of  the  neck  of  the  femur  are 
usually  impacted,  the  fragments  being  jammed  into  one  another ; 
the  crushed  cancellated  tissue  must  be  removed,  rendering  the 
process  of  repair  tedious. 

Bigelow,  who  has  devoted  a  great  deal  of  time  and  attention  to 
the  subject  of  injuries  about  the  hip-joint,  from  the  views  he  enter- 
tained as  to  the  architecture  of  the  femoral  neck,  was  convinced 
that  fracture  takes  place  most  frequently  at  the  base  of  the  neck, 
and  is  usually  accompanied  by  impaction  of  the  posterior  wall. 
The  cases  present  outward  rotation  of  the  limb  and  slight  shorten- 
ing, and  may  be  followed  by  complete  repair  without  lameness. 
Impaction  at  the  constricted  portion  of  the  neck  is  not  frequent. 
Impaction  of  the  entire  bone  of  the  neck  with  inward  rotation  of 
the  limb  is  very  rare,  and  is  hardly  possible  without  fracture  of  the 
trochanters. 

The  same  author,  at  a  meeting  of  the  Boston  Society  for  Medi- 
cal Improvement,  held  November  23,  1874,  exhibited  a  specimen 
of  a  fracture  within  the  capsular  ligament  with  imperfect  impaction 


IMPACTED  FRACTURES  OF  THE  NECK  OF  THE  FEMUR.    43 1 

which,  during  Hfe,  had  simulated  impaction  at  the  base  of  the  neck, 
and  induced  him  to  predict  a  favorable  prognosis.  "  The  autopsy- 
showed  that  the  fracture  was  not  through  the  base  of  the  neck,  but 
through  the  neck  itself,  close  to  the  head,  and  that  the  fragments 
were  '  rabbeted  '  together.  There  was  motion  enough  to  have  worn 
away  the  thin  walls  of  the  neck,  and  to  show  that  any  bony  union, 
had  the  patient  lived,  was  not  to  be  hoped  for.  In  this  respect  it 
differed  from  Dr.  Gay's  case  of  impacted  fracture  into  the  head, 
where  the  patient,  on  the  day  of  his  death  from  pneumonia,  a  week 
or  two  after  the  accident,  lifted  up  his  leg  and  said  that  as  far  as 
that  went  he  was  getting  well.  Had  that  man  lived,  he  would  un- 
doubtedly hav'e  had  bony  union  and  a  serviceable  leg.  The  rabbeting 
of  the  fragments  was  shown  here  very  well  in  the  present  specimen. 
It  was  due  to  a  conic  mass  of  comparatively  dense  bony  tissue  pro- 
jecting from  the  head  fragment,  which  was  driven  into  the  loose 
cancellated  structure  of  the  portion  of  the  neck  in  the  shaft  frag- 
ment. This  dovetailing,  although  sufficient,  while  the  fragments 
were  surrounded  by  the  capsule  and  soft  parts,  to  prevent  crepitus 
and  to  cause  the  neck  and  head  to  rotate  in  the  socket  as  a  whole, 
did  not  prevent  such  attrition  of  the  fragments  as  would  hinder 
bony  union." 

Koenig  locates  fractures  of  the  neck  of  the  femur  near  either 
the  head  or  the  trochanteric  portion,  localities  that  correspond  to 
intracapsular  and  extracapsular  fractures.  From  anatomic  reasons, 
after  a  fall  upon  the  trochanter  major  the  anterior  wall  of  the  neck 
(the  convex  side)  fractures  first  and  the  fractured  end  of  the  neck 
is  directed  forward.  In  most,  if  not  in  all,  cases  the  wedge-shaped 
end  of  the  inner  fragment  is  implanted  into  the  trochanteric  portion, 
producing  impaction.  Adams'  arch,  the  densest  and  strongest  por- 
tion of  the  neck,  penetrates  the  deepest.  The  greater  the  inclina- 
tion of  the  inner  fragment  forward,  the  more  extensive  the  impac- 
tion. As  a  necessary  result  of  this  impaction  the  head  of  the  femur 
descends  and  approaches  the  posterior  intertrochanteric  line  ;  the 
dislocation  of  the  head  in  these  directions  satisfactorily  explains 
the  shortening  and  outward  rotation  of  the  limb. 

Accurate  statistics  as  to  the  frequency  with  which  impacted  frac- 
tures occur  as  compared  with  nonimpacted  fractures  are  still  want- 
ing. The  individual  experiences  of  surgeons  arc  so  widely  at 
variance  on  this  point  that  a  final  decision  can  only  be  rendered 
after  the  accumulation  of  more  positive  knowledge  from  actual 
bedside  observations  and  postmortem  examinations.  From  a  study 
of  the  literature  it  is  apparent,  however,  that  the  more  recent 
authors  advance  the  opinion  that  it  is  of  frequent  occurrence.  It  is 
also  evident  that  impaction  is  not  limited  to  any  particular  part  of 
the  femoral  neck,  but  that  it  can  occur  in  any  fracture,  although 
the  most  favorable  conditions  for  its  occurrence  are  found  at  either 
extremity  of  the  femoral  neck.  The  direction  and  extent  of  im- 
paction depend   on   the  density  of  the  tissues  that  are  penetrated, 


432 


SPECIAL    FRACTURES. 


and  on  the  direction  and  intensity  of  the  fracturing  force.  Im- 
pacted fractures  within  the  capsule  may  occur  from  the  application 
of  indirect  violence,  as  the  capsular  ligament  will  offer  the  neces- 
sary resistance.  On  the  other  hand,  impacted  fractures  without 
the  capsular  ligament  can  only  take  place  from  direct  violence.  It 
is  also  possible,  in  cases  of  this  kind,  as  suggested  by  several 
authors,  that  a  simple  fracture  is  produced,  in  the  first  place,  by 
force  applied  through  the  axis  of  the  femur,  and  impaction  occurs 
subsequently  by  a  fall  upon  the  greater  trochanter. 

Impaction  from  indirect  violence  would  necessarily  take  place 
at  the  lower  portion  of  the  constricted  portion  of  the  neck,  by  the 
apex  of  the  femoral  brace  penetrating  the  soft  spongiosa  of  the 
head  (Fig.  273),  while  if  produced  by  a  fall  upon  the  trochanter 

major,  the  compacta  of  the  posterior  sur- 
face is  also  implanted  into  the  head.  Im- 
paction outside  of  the  capsule,  from  the 
normal  position  of  the  neck  and  the  direc- 
tion of  the  fracturing  force,  always  takes 
place  at  the  expense  of  the  posterior  por- 
tion of  the  neck,  except  in  cases  where 
the  fracturing  force  is  so  severe  as  to 
drive  the  entire  neck  into  the  upper  por- 
tion of  the  femoral  shaft  like  a  wedge, 
splitting  the  shaft  into  two  or  more  frag- 
ments. 

Impaction  implies  the  destruction  or 
crushing  of  more  or  less  bone  tissue  ; 
in  case  the  fragments  are  unlocked,  a 
vacuum  is  formed,  which  must  be  filled 
by  the  interposition  of  fluids  or  the  ad- 
jacent soft  tissues.  It  is  well  known  that 
intracapsular  fractures  are  often  produced 
by  very  slight  injuries,  and  it  is  equally 
certain  that  these  are  the  cases  that  fur- 
nish the  most  unfavorable  prospects  for  a  good  result,  and  the  ques- 
tion might  naturally  arise,  Had  the  violence  been  sufficient  to  pro- 
duce deep  penetration,  would  it  not  have  enhanced  the  prospects 
for  a  more  favorable  issue  ?  In  fractures  of  the  neck  of  the  femur 
the  prospects  for  a  good  result  are  better  if  the  exciting  cause  acts 
with  sufficient  intensity  to  produce  impaction,  as  this  condition  is 
the  best  adapted  to  repair  by  bony  union. 

Predisposing  Causes. — Fracture  of  the  neck  of  the  femur  is 
one  of  the  rarest  accidents  during  childhood  and  adult  life,  while 
after  the  fiftieth  year  it  constitutes  a  high  percentage  of  all  frac- 
tures. Between  the  twenty-first  and  thirtieth  years  it  constitutes 
-^Y  of  all  fractures  ;  between  thirty  and  forty,  J^  ;  between  fifty  and 
sixty,  nearly  -^^  ;  and  over  seventy,  i.  The  frequency  of  these 
fractures  increases  steadily  with  the  advance  of  old  age.      A  num- 


Fig.  273.  —  Intracapsular 
fracture  of  the  neck  of  the  femur, 
with  deep  penetration  of  Adams' 
arch  into  the  head  of  the  femur 
(Hoffa). 


EXCITING    CAUSES.  433 

ber  of  explanations  have  been  advanced  to  explain  this  clinical 
fact.  Thus,  Richter  mentions  the  following  predisposing  causes  : 
(i)  Spongy  texture  of  neck  and  diminution  in  thickness  of  com- 
pact layer.  (2)  Diminution  in  the  obliquity  of  the  neck.  (3) 
Prominence  of  trochanter  major,  by  which  the  fracturing  force  is 
transmitted  directly  to  the  neck. 

Walther  assigns  an  important  part  to  syphilis.  Sex  has  also 
been  mentioned  as  a  predisposing  cause  :  aged  females  furnish  a 
greater  number  of  fractures,  and  it  has  been  claimed  that  this  could 
be  accounted  for  by  the  more  horizontal  position  of  the  neck  in 
women,  owing  to  a  greater  width  of  the  pelvis.  As  the  strength 
of  the  neck  is  derived  from  the  peculiar  architectural  arrangement 
of  the  spongiosa,  the  simple  diminution  of  its  angle  would  not 
render  it  more  liable  to  fracture,  as  Julius  Wolff  has  shown  that, 
even  in  fractures  that  have  healed  with  considerable  deformity,  the 
structure  of  the  spongiosa  is  perfectly  restored,  in  accordance  with 
the  original  plan.  If  the  neck  is  placed  at  a  right  angle  to  the 
shaft,  it  would  give  way  more  easily  at  the  constricted  portion  on 
the  application  of  indirect  violence,  while  from  a  mechanical  stand- 
point it  ought  to  resist  force  more  advantageously  in  case  it  is 
applied  in  the  direction  of  the  long  axis  of  the  neck.  The  predis- 
posing cause  is  intrinsic,  inherent  in  the  bone  itself, — a  degenera- 
tion or  diminution  of  bone  tissue.  All  influences  that  affect  nutri- 
tion— and  that  of  bone  in  particular — hasten  the  degeneration  of 
bone.  Senile  osteoporosis,  then,  is  the  most  important  known 
predisposing  cause,  a  statement  abundantly  confirmed  by  clinical 
experience. 

Exciting  Causes. — Fractures  of  the  neck  of  the  femur  are  pro- 
duced by  : 

1.  Force  applied  in  a  vertical  direction  through  the  axis  of  the 
femur. 

2.  Force  applied  in  a  horizontal  direction  over  the  greater 
trochanter  in  the  axis  of  the  femoral  neck. 

3.  Traction  force  transmitted  through  the  capsular  ligament 
when  the  limb  is  forcibly  hyperextended,  adducted,  and  rotated 
outward. 

A  fall  upon  the  foot  or  knee  will  fracture  the  neck  of  the  femur 
at  its  narrowest  portion  ;  and  if  the  fracture  is  complete,  no  impac- 
tion will  follow  unless  it  takes  place  as  a  .secondary  occurrence 
from  transmission  of  force  through  the  greater  trochanter.  Most 
authorities  who  believe  that  intracapsular  fractures  are  the  most 
frequent  assert  that  indirect  violence  is  the  exciting  cause  most 
usually  encountered. 

Experiments  and  clinical  observation  have  shown  that  the 
majority  of  fractures  of  the  neck  are  produced  by  force  api:)lietl  in 
the  direction  of  the  axis  of  the  neck  by  falls  upon  the  trochanter 
major.  It  is  also  an  established  fact  that  in  mo.st  instances  of  this 
kind  the  neck  gives  way  at  its  trochanteric  portion,  and  that  the 
28 


434 


SPECIAL    FRACTURES. 


posterior  wall  is  crushed  or  fractured  first.  Impaction  takes  place 
more  frequently  from  direct  force,  with  deeper  penetration  of  the 
posterior  than  of  the  anterior  wall  of  the  neck. 

Of  thirty  cases  of  fracture  of  the  neck  examined  by  Desault  for 
the  purpose  of  learning  the  exciting  cause,  twenty -four  were  pro- 
duced by  a  fall  upon  the  trochanter  major.  All  the  cases  reported 
by  Sabatier  appear  to  have  been  produced  in  a  similar  manner. 
Sabatier  ascribed  to  the  prominence  of  the  greater  trochanter  an 
important  part  in  the  production  of  fracture,  and  believed  that  frac- 
ture of  the  femoral  neck  does  not  occur  in  children,  on  account  of 
the  imperfect  development  of  the  upper  extremity  of  the  femur. 

Although  direct  force  through  the  axis  of  the  neck  generally 
expends  itself  near  the  femoral  shaft,  causing  a  fracture  of  the 
expanded  portion  of  the  neck,  with  posterior  impaction,  there  are 
a  number  of  cases  recorded  where  the  fracture  occurred  within  the 
capsule.  Intracapsular  fractures  produced  in  this  manner  are  often 
impacted. 

Finally,  a  fracture  of  the  femoral  neck  may  be  produced  by 
forcible  hyperextension  and  rotation  outward  of  the  Hmb,  move- 
ments by  which  the  iliofemoral  ligament  is  stretched  to  its  utmost, 
and  when  the  bone  has  become  so  fragile  that  it  is  unable  to  resist 
the  traction  of  this  powerful  ligament,  a  fracture,  the  so-called 
traction  fracture,  takes  place  at  the  junction  of  the  neck  with  the 
femoral  shaft.  This  fracture  is  always  extracapsular,  and  was  first 
described  by  Linhart,  and  subsequently  experimentally  studied  by 
Riedinger.  Riedinger  believes  the  fracture  occurs  before  the  patient 
falls  upon  the  ground  ;  comminution  of  the  trochanter  major  and 
impaction  may  subsequently  result  from  direct  violence. 

Symptoms  of  Fractures  of  the  Neck  of  the  Femur. — As  the 
very  highest  authorities  are  forced  to  admit  that  during  life  it  is 
impossible  to  locate  accurately  the  precise  seat  of  fracture,  the  neces- 
sity for  considering  symptoms  separately  under  the  head  of  intra- 
capsular and  extracapsular  fracture  no  longer  exists.  In  practice 
the  greatest  care  should  be  exercised  to  ascertain  the  presence  of 
impaction  ;  but  even  impacted  fractures  present  the  most  important 
symptoms  in  common  with  nonimpacted  fractures,  and  they  may  be 
conveniently  grouped  together  to  prevent  unnecessary  repetition. 

The  symptoms  presented  by  a  fracture  through  the  neck  of  the 
femur,  as  in  any  other  fracture,  are  (i)  subjective  and  (2)  objective. 

The  subjective  symptoms  are  (i)  pain  and  (2)  loss  or  impair- 
ment of  function. 

I.  Pain. — The  pain  is  due  to  the  immediate  effects  of  the  trau- 
matism, to  laceration  of  the  contiguous  soft  tissues,  to  irritation 
produced  by  the  movements  of  the  fractured  ends,  or  to  the  inflam- 
mation of  the  bone  or  surrounding  tissues  succeeding  the  injury. 
The  pain  is  variable — almost  absent  and  of  short  duration  in  some 
cases,  excruciating  and  continuous  for  months  and  sometimes  years 
in  others.      If  the  fracture  is  located  in  the  narrow  portion  of  the 


SYMPTOMS    OF    FRACTURES    OF    THE    NECK    OF    THE    FEMUR.      435 

neck,  the  pain  is  usually  referred  to  the  groin,  at  about  the  insertion 
of  the  iliopsoas  muscle  ;  if  at  or  near  its  base,  it  is  more  diffuse  and 
referred  to  the  seat  of  injury. 

There  has  been  considerable  discrepancy  of  opinion  as  to  the 
severity  of  the  pain  in  fractures  within,  as  compared  with  fractures 
without,  the  capsule.  Sir  Astley  Cooper  maintained  that  it  is  less 
severe  in  the  former  variet\-,  while  Malgaigne  claimed  that  the 
reverse  was  true.  As  fractures  of  the  narrow  portion  of  the  neck 
are  the  result  of  less  violence  than  when  they  occur  near  the  shaft, 
it  is  undoubted!}-  true  that  the  pain  attending  them  immediately 
after  the  injury  is  milder  than  in  the  latter  class  of  injuries,  while 
the  reverse  may  be  true  during  the  subsequent  history  of  the  case. 
In  impacted  fractures,  where  the  favorable  conditions  for  bony  union 
are  not  disturbed  and  the  process  of  repair  is  instituted  at  once  and 
progresses  uninterruptedly,  the  pain,  as  a  symptom,  is  referable  only 
to  the  traumatism.  As  such,  as  a  rule,  it  is  severer  in  fractures 
where  the  greatest  amount  of  tissue  has  been  lacerated — that  is,  in 
extracapsular  fractures. 

In  cases  of  nonimpacted  fractures  within  the  capsule,  with 
motion  of  the  fragments  upon  one  another,  a  certain  amount  of 
inflammation  develops,  which  is  always  attended  by  its  most  promi- 
nent symptom — pain.  When  pain  the  result  of  inflammation  is 
present,  it  assumes  the  characteristic  features,  as  witnessed  in  coxitis 
independent  of  fracture.  It  is  then  no  longer  a  symptom  of  fracture, 
but  indicates  the  accession  of  coxitis.  The  presence  of  no  incon- 
siderable amount  of  inflammation  has  repeatedly  been  verified  at 
autopsies  in  the  form  of  thickening  of  the  capsule,  adhesions,  and 
destruction  of  the  synovial  membrane  and  cartilage.  Any  attempt 
at  motion  or  pressure  against  the  greater  trochanter  aggravates  the 
pain.  In  some  old  inveterate  cases  the  pain  assumes  a  neuralgic 
t\'pe,  which  would  indicate  that  some  of  the  nerves  about  the  hip- 
joint  were  encroached  upon  by  the  displaced  fragments,  exuberant 
callus,  or  the  products  of  inflammation. 

2.  Loss  or  Iinpainncnt  of  Function. — This  symptom  is  present 
in  all  fractures  of  the  femoral  neck.  As  a  general  rule,  it  may  be 
stated,  it  is  prominent  as  a  symptom  in  proportion  to  the  degree 
of  separation  of  the  fragments.  In  impacted  fractures  the  patients 
are  often  able  not  only  to  move  the  limb,  but  also  to,  walk  for 
hours,  and  sometimes  for  days.  The  range  of  motion,  however, 
is  always  diminished,  and  the  use  of  the  limb  is  attended  by  aggra- 
vation of  the  pain.  The  impairment  of  voluntary  movements  does 
not  depend  alone  on  the  direct  loss  of  support,  but  is  influenced  also 
by  the  pain  incident  to  such  movements  ;  hence  this  symptom  will 
present  itself  in  the  highest  degree  in  nervous,  excitable  patients. 
Laceration  of  the  soft  parts  of  the  periosteum  and  of  the  capsule, 
in  the  absence  of  impaction,  will  also  counteract  voluntary  motion, 
not  only  by  allowing  a  greater  degree  of  di.sjunction  of  the  frag- 
ments, but  likewise  by  increasing  the  pain  on  any  attempt  at  motion. 


436 


SPECIAL    FRACTURES. 


In  the  great  majority  of  cases  the  patient,  as  he  lies  in  bed,  is 
unable  to  raise  or  move  the  limb  in  any  direction — it  remains  per- 
fectly helpless  in  the  position  it  was  left  in  after  the  accident,  or  in 
which  it  has  been  left  by  the  displacing  elements.  In  some  cases, 
where  interlocking  of  the  fragments  exists  or  where  a  slight  amount 
of  impaction  has  taken  place,  the  patient  has  control  over  a  certain 
number  of  voluntary  movements  for  a  number  of  days,  or  until 
disjunction  of  the  fragments  takes  place  as  a  result  of  injudicious 
examination  or  inflammatory  osteoporosis,  when  the  limb  is  placed 
in  the  same  condition  as  if  no  impaction  had  occurred. 

The  objective  symp- 
toms are  :  (i)  Swelling  and 
deformity  at  the  hip ;  (2) 
suggillation  about  the  hip  ; 
(3)  eversion  of  limb ;  (4) 
shortening  ;  (5)  change  of 
position  of  trochanter  ma- 
jor ;  (6)  either  increased  or 
diminished  mobility  of  the 
hip-joint;  (7)  loss  of  ten- 
sion of  fascia  lata  between 
the  trochanter  major  and  • 
the  crest  of  the  ilium. 

I.  Swelling  and  De- 
formity.— In  all  cases  there 
is  an  appreciable  fullness  in 
the  fold  of  the  groin  cor- 
responding to  the  seat  of 
fracture.  This  swelling  is 
caused  by  the  hinge-like 
projection  of  the  anterior 
portion  of  the  neck,  effu- 
sion of  blood  or  inflamma- 
tory products,  and,  lastly,, 
by  the  overriding  or  im- 
paction of  the  fragments. 
When  impaction  takes  place 
at  the  base  of  the  neck,  the 
trochanteric  portion  of  the  femur  is  enlarged  from  implantation  of 
the  upper  fragment.  The  swelling  is  larger  when  the  fracture  is 
located  without  the  capsule,  from  the  more  extensive  bone  injury 
and  the  more  copious  effusion  of  blood. 

2.  Suggillation  appears  earlier  and  more  constantly  the  nearer 
the  fracture  is  seated  to  the  femoral  shaft.  As  this  symptom  is  the 
result  of  the  presence  of  blood  at  the  point  of  fracture,  it  is  more 
extensive  if  the  hemorrhage  has  been  severe  and  outside  of  the 
capsule.  If  the  hemorrhage  has  been  within  the  capsule  and  the 
capsule  is  ruptured  at  some  point,  the  discoloration   will   usually 


Fig.  274. — Unimpacted  fracture  of  the  neck 
of  the  femur,  showing  displacement  of  the  frag- 
ments and  faulty  position  of  the  limb  (Hoffa). 


SYMPTOMS  OF  FRACTURES  OF  THE  NECK  OF  THE  FEMUR.   43/ 

show  itself  along  the  inner  side  of  the  thigh.  The  same  force  that 
produced  the  fracture  may  also  contuse  the  soft  parts  sufficiently  to 
give  rise  to  superficial  discoloration  independently  of  the  fracture. 

J.  Evcrsion. — The  lower  limb  in  a  natural  condition  is  slightly 
everted,  on  account  of  the  forward  obliquity  of  the  femoral  neck. 
This  normal  eversion  is  increased  during  sleep,  when  the  muscles 
are  at  rest,  when  they  have  been  completely  relaxed  by  a  general 
anesthetic,  or  when  their  action  has  been  permanently  suspended 
by  paralysis.  In  the  normal  condition,  then,  the  weight  of  the 
limb  effects  outward  rotation  until  arrested  by  muscular  action  or 
the  resistance  offered  by  the  ligaments  of  the  hip-joint.  As  the 
posterior  wall  of  the  neck  is  usually  the  seat  of  more  extensive 
comminution  or  impaction  than  the  anterior,  and  as  the  fracturing 
force,  in  the  majority  of  cases,  is  applied  in  the  anterolateral  direc- 
tion, it  is  only  reasonable  to  expect  that  outward  rotation  of  the 
limb  is  the  rule.  Until  recently  it  has  been  generally  taken  for 
granted  that  eversion  is  the  result  of  muscular  contraction.  In 
support  of  this  view  it  has  been  suggested  that,  in  nonimpacted 
fractures,  it  increases  after  the  muscles  have  recovered  their  con- 
tractility. 

Edmund  Owen,  basing  his  opinion  on  anatomic  demonstrations 
and  carefully  made  experiments,  as  well  as  accurate  clinical  obser- 
vation, holds  that  eversion  of  the  limb  takes  place  independently 
of  muscular  contraction  ;  that  it  is  invariably  the  result  of  the  im- 
pacting force  or  the  weight  of  the  limb,  as  the  case  may  be.  In 
intracapsular  fractures  it  is  especially  true  that  eversion  is  more 
marked  a  few  days  after  the  injury,  but  this  fact  can  be  explained 
more  satisfactorily  from  a  different  standpoint.  In  such  cases  the 
fragments  are  often  kept  in  apposition  by  an  interlocking  of  the 
broken  surfaces  or  untorn  portions  of  the  fibrous  investment  of  the 
neck.  Either  of  those  supports  may  give  way  to  the  constant  trac- 
tion from  the  weight  of  the  limb,  or  the  same  result  may  follow 
reflex  muscular  contractions  or  careless  handling  of  the  limb.  The 
great  mass  of  muscles, — the  external  rotators  of  the  hip, — after  the 
fracture,  are  relaxed,  from  the  approximation  of  their  points  of  origin 
and  in.sertion,  and  it  is  difficult  to  conceive  in  what  way  they  could 
effect  outward  rotation. 

Dupuytren  believed  that  eversion  may  also  be  due  to  the  action 
of  the  adductor  muscles,  and  in  some  instances  to  the  obliquity  of 
the  fracture  itself.  It  is  also  necessary  to  mention  that  eversion  is 
not  a  constant  symptom.  Cases  have  been  described  by  reliable 
observers  where  the  limb  remained  normal  so  far  as  the  position  of 
the  foot  was  concerned,  and  in  some  even  the  reverse — inversion — 
occurred.  Ca.ses  of  fracture  with  inversion  have  been  described  by 
Ambroi.se  Pare,  J.  L.  Petit,  Guthrie,  S.tanley,  Dupuytren,  Desault, 
Cruveilhicr,  Hamilton.  R.  W.  Smith,  and  others.  Desault  thought 
that  it  occurred  in  about  one  ca.se  out  of  every  four.  Stanley 
ob-served  one  case  where  the  autopsy  showed  that  the  fracture  was 


438  SPECIAL    FRACTURES. 

purely  intracapsular,  and  no  satisfactory  explanation  could  be  found 
for  the  inversion.  Wm.  Pirrie  mentions  a  case  of  intracapsular  frac- 
ture where  the  limb  was  not  only  inverted,  but  also  strongly  flexed 
and  adducted,  a  position  he  ascribed  to  the  tension  of  the  iliofemoral 
ligament.  Of  the  130  cases  of  intracapsular  fracture  of  the  neck  of 
the  femur  that  came  under  Pirrie's  observation,  and  where  the  accu- 
racy of  the  diagnosis  was  verified  by  dissection,  this  was  the  only 
case  with  flexion,  adduction,  and  rotation  inward  of  the  limb.  Of 
the  remaining  number,  in  one  case  only  inversion  existed,  the  limb  ni 
other  respects  occupying  the  usual  straight  position.  Malgaigne 
reports  an  exceedingly  interesting  case:  "In  1833,  having  found 
the  foot  inverted  in  a  fracture  of  the  neck  of  the  femur,  I  ascertained 
that  it  was  easily  everted  and  again  inverted  at  will,  and  that  it 
remained  as  readily  in  one  position  as  in  the  other ;  whence  I  con- 
cluded whatever  inclination  is  given  to  the  part  upon  the  supporting 
plane  it  keeps  by  its  ozvn  weight."  This  observation  is  exceedingly 
valuable,  and  would  lead  us  to  the  conclusion  that  whenever  the 
support  derived  from  the  cervical  portion  of  the  femur  is  lost,  the 
limb  will  follow  the  natural  law  of  gravitation,  and  will  turn  out- 
ward by  its  own  weight,  unless  opposed  by  some  special  conditions 
at  the  seat  of  fracture  or  by  external  influences. 

^.  Shortening. — The  significance  of  shortening  as  a  symptom 
of  fracture  of  the  neck  of  the  femur  has  received  additional  interest 
since  it  has  been  ascertained  that  in  many  persons  there  is  normally 
a  difference  in  the  length  of  the  lower  extremities  in  the  same 
individual.  Wight,  of  Brooklyn,  has  made  a  valuable  contribution 
to  surgery,  relating  to  the  comparative  length  of  the  inferior  ex- 
tremities in  the  same  person.  His  first  pubUshed  table  comprised 
the  results  of  measurements  of  60  persons  of  varied  nationalities, 
pursuits,  and  ages.  In  these  there  were  10  persons  who  presented 
perfect  symmetry  of  length  in  the  two  legs,  and  50  who  showed  an 
asymmetry  varying  from  j^  of  an  inch  to  i  ^  inches.  The  right 
leg  was  the  longer  in  18,  and  the  left  in  32. 

A  second  table  comprises  42  measurements,  and  shows  a  parity 
of  length  in  13  and  a  difference  in  29  instances,  the  difference 
varying  from  one-fourth  of  an  inch  to  one  inch.  In  9  cases  the 
right,  and  in  20  the  left,  limb  was  the  longer.  F.  H.  Hamilton  cor- 
roborated the  correctness  of  these  results  by  his  own  researches. 

These  measurements  not  only  prove  that  the  lower  limbs  differ 
in  length  in  a  majority  of  cases  examined,  but  likewise  point  out 
the  importance  of  measuring  the  long  bones  separately  for  the  sake 
of  comparison  when  measurements  are  made  for  diagnostic  pur- 
poses. 

More  or  less  shortening  will  take  place  in  every  case  of  fracture 
of  the  neck.  M.  Lisfranc  and  M.  Lallemand  each  have  reported  a 
case  where  the  limb  was  longer.  It  is  impossible  to  conceive  in 
what  manner  the  fracture  could  add  to  the  length  of  the  limb  ;  and 
still  the  observations  undoubtedly  were  correct,  and  an  explanation 


SYMPTOMS  OF  FRACTURES  OF  THE  NECK  OF  THE  FEMUR.   439 


can  be  given  only  by  assuming  that  the  amount  of  actual  shorten- 
ing was  slight,  and  the  patient's  limbs  were  of  unequal  length. 
The  amount  of  shortening  depends  on  the  degree  of  disjunction  : 
the  greater  the  longitudinal  displacement,  the  greater  the  shorten- 
ing. The  shortening  is  always  the  direct  result  of  muscular  con- 
traction or  longitudinal  displacement  by  impaction.  In  impacted 
fractures  the  maximum  is  reached  at  once,  and  the  degree  of  short- 
ening depends  on  the  depth  of  penetration  or  mutual  interpenetra- 
tion  of  the  fractured  ends. 
In  cases  of  impaction  the 
shortening  remains  station- 
ary, as  the  fracture  is  not 
disturbed,  and  can  increase 
only  on  the  advent  of  in- 
flammatory interstitial  ab- 
sorption. In  fractures  with- 
out the  capsule,  all  resist- 
ance to  muscular  contrac- 
tion is  lost,  and  the  maxi- 
mum amount  of  shortening 
is  reached  as  soon  as  the 
muscles  have  become  con- 
tracted. If  the  capsule  is 
intact  and  remains  attached 
to  the  lower  fragment, 
shortening  takes  place 
gradually  by  stretching  of 
the  capsular  ligament.  In 
case  the  fragments  are  held 
in  contact  by  the  denticu- 
lated fractured  surface, 
shortening  can  proceed 
only  after  this  medium  of 
apposition  has  been  re- 
moved, by  displacement  of 
the  bones,  or  after  inflam- 
matory osteoporosis  has 
removed  the  projecting 
spicula.      This  condition  is 

often  met  in  intracapsular  fractures.  The  degree  of  shortening 
immediately  after  a  fracture  has  been  relied  upon  by  some  in  deter- 
mining the  scat  of  fracture.  Among  surgeons  there  has  been,  how- 
ever, such  discrepancy  of  opinion  in  this  respect  that  no  reliable 
deductions  can  be  drawn  from  this  circumstance  in  rendering  a 
decision. 

.Sir  Astley  Cooper  and  Amcsbury  claim  the  greatest  shortening 
for  intracapsular  fractures,  while  .Stanley,  Earle,  and  R.  W.  Smith 
entertained  an  opposite  view.      Impaction   and  the   integrity  of  the 


Fig.  275. — Roser-Nelaton  line  :  a.  Anterior 
superior  spinous  process  of  ilium  ;  />,  upper  border 
of  trochanter  major  ;  c,  tuberosity  of  ischium. 


440 


SPECIAL    FRACTURES. 


capsular  ligament  are  such  important  factors  in  determining  the 
amount  of  shortening  and  the  time  of  its  occurrence  that  these 
conditions  must  be  carefully  considered  in  estimating  the  value  of 
shortening  as  a  diagnostic  aid. 

5.  Change  of  Position  of  Trochanter  Major. — The  greater  tro- 
chanter is  displaced  upward  and  backward  in  proportion  to  the 
extent  of  shortening  and  eversion.  When  shortening  has  occurred, 
its  upper  margin  has  passed  above  the  Roser-Nelaton  line,  which  is 
a  straight  line  drawn  from  the  anterior  superior  spine  of  the  ilium  to 
the  tuberosity  of  the  ischium  (Fig.  275).     This  line  is  of  the  greatest 

diagnostic  value,  not  only  in  ex- 
aminations for  fracture  of  the 
ilium,  but  also  in  ascertaining 
the  existence  of  shortening  of 
the  limb  caused  by  inflammatory 
affections  of  the  hip-joint.  In 
a  normal  condition  the  upper 
margin  of  the  greater  trochanter 
is  on  a  level  with  the  Roser- 
Nelaton  line.  In  fractures  of 
the  neck  of  the  femur  the  tro- 
chanter major  describes  a  smaller 
arc  of  a  circle  on  rotation  of  the 
femur.  The  diminution  in  the  arc 
of  circle  is  less  in  impacted  frac- 
tures and  when  the  lower  frag- 
ment is  not  in  apposition  with 
the  upper. 

6.  Alteration  of  Motion. — A 
false  point  of  motion  is  always 
established  in  nenimpacted  frac- 
tures. Preternatural  mobility  is 
most  marked  if  the  fracture  is  not 
impacted  and  located  outside  of 
the  capsule.  It  is  probably  in 
cases  of  this  kind  that  Gerdy  has 
been  able  to  rotate  the  limb  out- 
ward until  the  toes  were  directed  backward,  and  that  Maisonneuve 
brought  into  requisition  his  test  of  hyperextension.  If  the  fracture 
is  within  the  intact  capsule,  the  latter  will  serve  as  a  retentive  meas- 
ure and  limit  the  motion  between  the  fractured  ends.  Levis  dis- 
covered that  in  nonimpacted  fractures  the  limb  can  be  extended 
beyond  its  normal  length.  In  case  firm  impaction  has  taken  place, 
the  neck  has  become  shorter  and  thicker,  conditions  that  necessarily 
impair  the  normal  mobility  of  the  hip-joints. 

7.  Fascia  Lata. — Allis,  of  Philadelphia,  has  added  another 
symptom  that  indicates  fracture  through  the  neck  of  the  femur — 
namely,  the  existence  of   a  relaxed   condition   of  the  fascia    lata 


Fig.  276. — Loss  of  tension  of  fascia 
lata  in  fractures  of  the  neck  of  the  femur 
(Hoffa). 


DIAGNOSIS. 


441 


between  the  crest  of  the  ihum  and  the  greater  trochanter  on  the 
injured  side,  produced  by  the  loss  of  resistance  which  is  furnished 
by  the  neck  when  not  broken.  As  the  presence  of  this  symptom 
depends  on  the  dislocation  of  the  lower  fragment  upward  and  in- 
ward, it  is  met  only  when  such  changes  have  taken  place.  The 
standing  position  is  the  only  one  in  which  this  test  can  be  applied 
(Fig.  276),  as  in  the  reclining  position  the  muscles  that  make  tense 
the  fascia  are  relaxed. 

Bezzi  has  called  attention  to  a  sign  that  he  considers  as  pathog- 
nomonic of  fracture  of  the  neck  of  the  femur.  In  examining  the 
space  between  the  trochanter  and  the  crista  ilii,  it  will  be  found  that 
while  on  the  same  side  the  muscles  occupying  this  region  (the 
tensor  vaginae  femoris  and  the 
gluteus  medius)  are  tense  and 
offer  to  the  hand  a  considerable 
feeling  of  resistance,  they  present 
on  the  affected  side  a  deep,  well- 
marked  depression,  flaccidity, 
and  diminution  of  tension  from 
displacement  upward  of  their 
points  of  insertion.  The  sign 
appears  under  the  same  circum- 
stances and  possesses  the  same 
significance  as  the  one  described 
by  Dr.  Allis. 

The  mention  of  crepitus  as  a 
symptom  has  been  omitted  in- 
tentionally, as  more  harm  than 
benefit  has  accrued  from  the 
efforts  of  the  anxious  surgeon  to 
establish  a  positive  diagnosis  on 
the  presence  or  absence  of  this 
sign.  A  careful  study  of  the 
other  symptoms  will  usually  en- 
able us  to  arrive  at  a  correct  con- 
clusion, without  exposing  the  patient  to  the  risks  incident  to  the 
manipulations  neccs.sary  for  the  purpose  of  eliciting  this  symptom. 

Diagnosis. — All  manipulations  during  the  examination  of  a 
supposed  fracture  through  the  cervix  femoris  should  be  performed 
with  the  utmo.st  care  and  gentleness.  The  so-called  "  thorough 
examination,"  the  search  for  positive  symptoms,  has  been  the 
source  of  incalculable  mischief  In  many  instances  careless  hand- 
ling of  the  limb  has  resulted  in  di.sjunction  of  impacted  fractures 
or  in  tearing  of  periosteal  or  ligamentous  bands,  thus  most  effec- 
tually precluding  possible  union  by  bone  or  the  formation  of  a  short 
fibrous  union.  Years  ago  Davis  entered  his  protest  against  such 
reckless  examinations  in  the  fcjllowing  emphatic  language  :  "  Now, 
while  we  willingly  conccdi-  the  importance  of  a  correct  diagnosis 


Fig.  277. — Anterior  view  of  bony 
union  after  fracture  of  neck  of  femur 
(Hutchinson). 


442 


SPECIAL    FRACTURES. 


in  its  bearings  upon  the  successful  treatment  of  any  case,  we  hold 
that  too  much  handling  and  manipulation  of  the  limb  in  intra- 
capsular fracture  is  liable  to  eventuate  in  irreparable  injury  to  the 
patient."  Again:  "When  this  connecting  link  of  periosteum  and 
capsular  ligament  is  not  severed  by  officious  handling  on  the  part 
of  the  surgeon  in  his  zealous,  but  often  mischievous,  efforts  to 
ascertain  to  the  fullest  extent  the  details  of  the  injury,  then  we 
may  hope  for  better  results  than  have  usually  followed  this 
accident." 

T.  Bryant's  caution  is  equally  strong  :  "  In  fact,  the  ordinary 
fracture  at  the  base  of  the  neck  of  the  thigh  bone  is  primarily  an 
impacted  fracture,  the  impacted  bone  in  some  cases  being  loosened 
by  a  second  fall,  in  others  by  excess  of  violence  received  in  the 
original  accident,  and  in  too  many  by  the  manipulatioits  of  the  sur- 
geon in  his  anxiety  to  make  out  the  presence  of  a  fracture  by  the 
detection  of  crepitus.  Indeed,  this  seeking  for  crepitus  in  cases  of 
fracture  is  a  practice  fraught  with  danger." 

In  every  case  of  suspected  fracture  we  should  make  careful 
search  for  evidences  of  senile  osteoporosis,  and  ascertain,  as  nearly 
as  possible,  the  degree  of  force  applied  and  the  direction  of  its  appli- 
cation. If  the  general  appearances  of  the  patient  indicate  the  exist- 
ence of  far-advanced  senile  osteoporosis,  and  if  the  degree  of  force  has 
been  slight  and  was  applied  in  the  direction  of  the  axis  of  the  femur, 
it  is  more  than  probable  that  the  fracture  has  occurred  within  the 
capsule.  If  the  fracturing  force  has  been  greater  and  was  applied 
transversely  in  the  axis  of  the  femoral  neck,  we  have  reason  to  sus- 
pect that  the  fracture  has  taken  place,  at  least  partly,  without  the  cap- 
sule. The  sudden  and  complete  loss  of  function  of  the  limb  after 
an  injury  to  the  hip  in  a  person  over  fifty  years  of  age  speaks 
strongly  in  favor  of  a  fracture  through  the  femoral  neck.  We  can 
say,  with  Hodgson  :  "  If  an  elderly  person,  after  a  fall  upon  the 
hip,  is  unable  to  use  the  injured  limb,  it  is  very  probable  that  a 
fracture  of  the  neck  of  the  femur  has  been  sustained,  and  this  is 
more  likely  to  be  the  case  if,  during  the  fall,  no  such  great  force 
has  acted  upon  the  greater  trochanter  as  would  be  necessary  to  pro- 
duce a  contusion  sufficiently  severe  to  render  the  limb  useless." 

Aside  from  a  general  consideration  of  the  case,  the  diagnosis 
will  depend  on  the  presence  or  absence  of  the  two  most  important 
symptoms,  shortening  and  eversion.  Many  of  our  best  surgeons 
depend  almost  exclusively  on  accurate  measurements  in  rendering 
a  diagnosis.  The  extent  of  immediate  shortening  will  vary,  accord- 
ing to  the  presence  or  absence  of  impaction,  from  a  few  lines  to 
two  inches.  In  impacted  fractures  the  shortening  is  immediate  and 
remains  stationary,  unless  displacement  takes  place  or  if,  during  the 
reparative  process,  the  femoral  neck  is  shortened  by  interstitial 
absorption.  The  progressive  shortening  a  (qw  days  after  the  acci- 
dent is  due  to  a  loosening  of  the  fragments  that  have  been  in  mutual 
contact  by  denticulated  projections,  and  to  a  gradual  stretching  of 


DIAGNOSIS.  443 

untorn  portions  of  the  capsular  ligament.  Mr.  Bryant,  in  speaking 
of  the  utility  of  his  "  test-line,"  says  :  "  Indeed,  as  a  proof  of  its  use, 
I  may  add  that  twenty-five  consecutive  cases  of  fracture  of  the  neck 
of  the  thigh  bone  admitted  into  my  wards  to  the  end  of  1877  (the 
average  age  of  the  patients  being  seventy-four)  left  the  hospital 
with  union  of  the  broken  bones  and  useful  limbs." 

J.  S.  Wight,  of  Brooklyn,  has  written  an  exceedingly  interest- 
ing and  practical  paper  on  diagnosis  of  fractures  of  the  femoral 
neck,  based  on  the  report  of  twenty-one  cases.  For  the  purpose 
of  avoiding  errors  that  might  accrue  from  asymmetry  of  the  lower 
extremities,  he  directs  that  the  following  measurements  should  be 
taken  :  ' 

"  I.  Inside  measurements  from  the  superior  anterior  spines  of 
the  ilium  to  the  lower  ends  of  the  internal  malleoli. 

"  2.  Outside  measurements  from  the  anterior  spines  of  the 
ilium  to  the  lower  ends  of  the  external  malleoli. 

"  3.  Measurements  from  the  tops  of  the  greater  trochanters  to 
the  lower  ends  of  the  external  malleoli. 

"  4.  Measurements  from  the  bases  of  the  tibiae  to  the  lower 
ends  of  the  internal  malleoli. 

"5.  Measurements  from  the  superior  anterior  spines  of  the 
ilium  to  a  line  drawn  transversely  in  front,  between  the  tops  of  the 
greater  trochanters." 

The  object  of  all  these  comparative  measurements  is  to  deter- 
mine the  possibility  of  original  asymmetry  of  the  two  limbs,  and 
to  determine,  so  far  as  possible,  if  the  injury  to  the  hip  has  caused 
any  shortening  of  the  limb  on  the  injured  side,  so  that  we  can 
infer  the  probability  of  the  existence  of  a  fracture  of  the  femoral 
neck.  He  gives  the  results  of  examination  of  twenty-one  such 
fractures,  where  a  diagnosis  was  made  without  eliciting  crepitus. 
In  eight  of  these  cases  there  was  probably  impaction.  The  average 
shortening  was  -^-^  of  an  inch,  as  shown  by  the  inside  and  outside 
measurements.  In  no  case  of  fracture  of  the  femoral  neck  does 
he  use  force  to  elicit  crepitus.  He  considers  the  other  evidences 
of  fracture  as  sufficient  for  reaching  a  practical  conclusion.  His 
concluding  statements  contain  so  many  practical  and  useful  sug- 
gestions that  they  are  given  in  detail  here  : 

"I.  Moving  the  outer  fragment  when  it  is  in  contact  with  the 
inner  fragment  will  generally  carry  the  inner  fragment  with  it,  and 
there  will  be  no  crepitus  ;  and  when  there  is  impaction,  ordinary 
manipulation  will  not  cau.se  crepitus  to  be  felt.  Yet  crepitus  may, 
at  times,  be  felt  when  there  is  impaction  of  the  neck  of  the  femur. 

"  2.  Moving  the  outer  fragment  when  it  is  not  in  contact  with 
the  inner  fragment  of  course  will  not  give  crepitus. 

"  3.  Hence  unwarrantable  force  will  be  required  in  order  to  get 
crepitus  in  many  cases  of  fracture  of  the  neck  of  the  femur,  and, 
more  than  tiiis,  an  impacted  fracture  of  the  neck  of  the  feini/r  maybe 
broken  up  by  severe  manipulation,  and  a  patient  that  would  have  had 


444  SPECIAL    FRACTURES. 

a  useful  limb  may  be  quite  completely  disabled  for  life,  for  an  impacted 
fracture  of  the  neck  of  the  femur  is  the  best  setting  of  the  bony  frag- 
ments that  a  surgeon  can  have. 

"  In  a  suspected  fracture  of  the  neck  of  the  femur  I  examnie  all 
the  witnesses  of  fracture  except  crepitus,  and  if  these  witnesses 
ao-ree  substantially,  I  pronounce  a  verdict  in  favor  of  fracture  of  the 
neck  of  the  femur  ;  and  if  there  is  a  doubt  as  to  the  correctness  of 
such  a  verdict,  I  give  the  patient  the  benefit  of  that  doubt  by  treat- 
ing the  case  as  if  there  was  a  fracture  of  the  neck  of  the  femur,  and 
then  the  surgeon  receives  a  benefit  from  the  doubt.  But  if  there  is 
no  fracture,  the  patient  has  had  some  days  of  needful  rest  and  has 
had  a  contused  hip  well  treated." 

The  instrument  recommended  is  an  accurate  steel  tape-line,  with 
feet  and  inches  indicated  on  one  side,  and  meters  and  centimeters  on 
the  other  side.  This  tape-line  will  not  elongate  under  tension.  It 
is  superfluous  to  mention  that  the  patient  should  be  placed  in  the 
recumbent  position,  on  an  even  surface,  when  the  measurements 
are  taken.  It  is  to  be  hoped  that  the  text-books  of  the  future  will 
say  less  of  crepitus  as  a  sign  of  fracture,  and  will  advocate,  instead, 
accurate  methods  of  measurement. 

Eversion  of  the  limb  is  the  next  most  reliable  symptom.  In 
impacted  fractures  the  position  of  the  limb  depends  on  the  direction 
of  the  fracturing  force.  If  the  force  acts  in  the  direction  of  the 
axis  of  the  cervix  and  is  severe,  causing  implantation  of  the  whole 
base  of  the  neck  into  the  trochanteric  portion  of  the  femur,  the 
limb  will  retain  its  natural  position.  If  the  anterior  wall  is  impacted 
by  force  applied  against  the  outer  and  posterior  aspect  of  the  tro- 
chanter major,  the  limb  will  remain  in  a  position  of  inward  rotation. 
Owing  to  the  anterior  obliquity  of  the  neck,  the  usual  manner  of 
falling  (forward  and  on  the  side),  and  the  thinness  of  the  compacta 
of  the  posterior  concave  surface  of  the  neck  as  compared  with  the 
anterior,  we  would  naturally  infer  that  posterior  impaction  takes 
place  in  the  great  majority  of  cases.  This  supposition  has  been 
abundantly  verified  by  clinical  observation.  Impaction,  then,  is 
usually  attended  by  eversion.  If  the  fracture  is  located  within  the 
capsule,  eversion  frequently  will  increase  for  a  few  days  or  weeks 
after  the  accident,  from  the  same  causes  that  give  rise  to  secondary 
shortening.  In  cases  of  posterior  impaction  where  the  fragments 
remain  firmly  implanted  during  the  process  of  repair,  eversion  in- 
creases from  the  weight  of  the  limb  and  the  inflammatory  absorp- 
tion of  the  impacted  fragments,  permitting  increased  rotation  out- 
ward of  the  lower  fragment.  The  abnormal  position  of  the  greater 
trochanter  is  also  an  important  diagnostic  sign.  If  we  can  exclude 
dislocation  of  the  hip-joint  upward  and  backward,  the  application 
of  the  Roser-Nelaton  test  may  decide  the  diagnosis.  In  cases  of 
fracture  of  the  neck  of  the  femur  the  upper  border  of  the  greater 
trochanter  will  be  found  above  the  Roser-Nelaton  line,  the  distance 
corresponding  with   the  amount   of  shortening.      In   nonimpacted 


DIAGNOSIS. 


445 


fractures  the  false  point  of  motion  diminishes  the  arc  of  rotatton  that 
the  .greater  trochanter  describes  ui  rotatmg  the  hmb.     This  s>mp 
om°s  mentioned  simply  to  be  condemned   as  the  mampulafons 
necessary  to  apply  this^est,  like  the  search  for  crepitus,  have  done 
a  crreat  deal  more  harm  than  good. 

°  In  doubtful  cases,  more  particularly  when  dislocation  is  sus- 
pected  the  patient  should  be  carefully  placed  in  the  erect  position, 
when  the  position  of  the  limb  and  an  examination  of  the  contour 
rf  the  hip,'^as  well  as  an  inspection  of  all  the  landmarks  in    ha 
locality     will    render   material    assistance    in    arriving   at    con  ect 
d"ati  ostic  conclusions.     In  case  of  doubt,  if  we  err  at  all   it  should 
he  on  the  safe  side  and  we  should  treat  the  case  as  one  of  fracture. 
Many  cases    ha   were  in  a  most  favorable  condition  for  bony  union 
have  been  rendered  hopeless  by  a  disregard  for  this  rule.    The  sur- 
g:::,  must  ever  bear  in  mind  that  the  most  favorable  cases  present 
The  least  degree  of  deformity,  and  that  in  our  anxiety  to  make  a 
con  ect  diagnosis  we  sacrifice  all  the  conditions  that  are  essential 
for  obtaining  bony  union.  .  .  . 

In  response  to  a  circular  sent  by  me  inquinng  as  to  the  possi- 
bility of  bony  union  after  impacted  intracapsular  fracture.  Professor 
AC   Post  of  New  York,  after  replying  in  the  affirmative,  kindly 
wrote  :  ••  But  the  difficulty  in  proving  this  proposition  depends  on 
two  circumstances  ■    (l)  The  want  of  absolute  determination  that 
rct^r: "tu^llyU'curred.  and  (.)  the  w-^t  of  oppoitun^  to 
demonstrate,  by  autopsy,  that  bony  union  has  ^<:'"^'^  °'=="'^^;°^ 
It  is  a  common  thing  for  a  person  of  advanced  age  '«■"<;«' «'*J'" 
accident  rendering  him  or  her  unable  to  stand  or  walk  or  to  raise 
he  afiScte"  limb  from  the  bed.     There  is  a  certain  amount  of  pain 
and    lameness    about   the    hip,  with   eversion  of  the   toes  and  a 
scarc'rperceptible  shortening  of  the  limb.     On  careful  examina- 
tion'wftlfout  u'sing  much  force  neither  crepitus  nor  abnormal  motion 

"".^Th^r^t  probable  evidence,  but  not  certain  demonstration   of 
impacted  intr.4psularfracture^    If  the  surgonis  CO  t.^^^^^^^^ 

're  ;;:;"uk  s'^Sn  ih'l  7*ctl  somid  limb  But  the  proof 
S  ^heCure  'and  reunion  fs  incomplete.  ^  ^^^^f^  Ij  '^ 
anxiety  to  obtain  a  perfect  diagnosis,  moves  the  !™b  h  tely  n  a" 
dh-ections  he  overcomes  the  impaction,  ruptunng  the  cervical 
fig  m  nt  dlonstrates  beyond  all  doubt  the  existence  of  the  frac- 
ture, and  effectually  destroys  al  hope  of  «""'°"  .  7°;^^,^  f^b 
I  prefer  an  imperfect  diagnosis  for  the  ^"■8'=°"  a"^/ PJ*„',  '™d 
for  the  patient,  rather  than  a  perfect  diagnosis  foi  the  suigeon  ana 

,1  useless  limb  for  the  patient."  concise 

These   remarks   require   no   explanation.       They  a  e  co^icise 
plain,  practical,   and  to    the  point.     Un.nipacted  fractures  ot  the 
'neck  of  the  femur  seldom  give  rise  to  any  d'^cu  ^   n  d^agno.  is 
the  symptoms  attending  them  are  so  well  maiked  that  a  collect 


446 


SPECIAL    FRACTURES. 


conclusion  can  be  reached  without  causing  needless  suffering  or 
sacrificing  important  tissues  in  searching  for  any  one  particular 
positive  sign.  Fractures  with  impaction  present  the  same  symp- 
toms in  a  minor  degree  ;  their  presence  can  usually  be  recognized 
by  a  careful  consideration  of  symptoms,  the  elucidation  of  which 
does  not  necessitate  the  disengagement  of  the  fragments  ;  and, 
finally,  if  we  have  reason  to  believe  that  a  fracture  with  impaction 
exists,  although  the  symptoms  are  not  sufficiently  well  marked  to 
warrant  the  diagnosis,  it  is  our  duty  to  initiate  the  treatment  in 
accordance  with  such  a  supposition. 

Specimens  of  Bony  Union  after  Extracapsular  Fracture. — 
It  is  not  my  intention  to  enter  into  a  discussion  of  the  merits  of 
the  many  specimens  for  which  bony  union  has  been  claimed  by 
their  possessors.  Many  of  them  have  been  the  object  of  the  most 
rigid  criticism,  at  different  times  and  at  the  hands  of  various  writers. 
While  careful  and  competent  men  have  brought  their  specimens  to 
the  attention  of  the  profession  as  typical  examples  of  union  by 
bone  within  the  capsule,  equally  capable  observers  have  failed  to  see 
the  evidences  that  justified  these  claims.  I  have  tabulated  only 
the  cases  reported  by  competent  observers  up  to  1883,  and  where 
the  diagnosis  was  verified  by  a  postmortem  examination.  To  these 
I  have  added  the  case  that  came  under  my  own  observation, 
described  in  the  first  part  of  this  section. 


TABULATED   SPECIMENS  OF   BONY   UNION   AFTER    INTRACAPSULAR 

FRACTURE. 


No. 

Name  of 
Reporter. 

I 

Adams,  R., 

2 

Adler, 

3 

Bardeleben, 

4 

Brulatour, 

5 
6 

Bryant, 
Callender, 

7 
8 

Chassaignac, 
Chelius, 

Q 

Chelius, 

10 

Cushing, 

II 

Earle, 

12 

Fawcington, 

IS 

Field, 

14 

Fischer,  H., 

IS 

Fischer,  H., 

16 

Geddings, 

17 

Gurlt, 

18 

Hamilton, 

19 

Harris, 

20 

Holthouse, 

21 

Howship, 

Where  Mentioned  or  Classified. 


Todd's  "Cyclopedia,"  vol.  11,  p.  813, 
"Am.  Jour.  Med.  Sci.,"  April,  1873. 
"  Lehrbuch  d.  Chir.,"  Bd.  n,  S.  477. 
"Med.-Chir.  Trans.,"  vol.  XIII. 
Bryant's  "Surgery,"  p.  843. 
"St.  Barthol.   Hosp.   Rep.,"  vol.  i, 

P-    154; 

"These  inaugurale." 

"Handb.  d.  Chir.,"  Bd.  i,  S.  319. 

"Handb.  d.  Chir.,"  Bd.  i,  S.  319. 

Bigelow,  "The  Hip,"  p.  133. 

"  Practical  Obser.  in  Surgery,"  1823, 

p.  97. 
"Am.    Jour.    Med.    Sci.,"    vol.   xv, 

P-   534- 
Amesbury  on  "  Fractures." 
Personal  communication. 
Personal  communication. 
"Am.  Jour.  Med.  Sci.,"  Jan.,  1847. 
"  Knochen-Briiche,"  vol.  i,  p.  308. 
Hamilton  on  "Fractures,"  p.  407. 
"Am.  Jour.   Med.   Sci.,"  vol.  xviii, 

p.   246. 
Holmes'  "System  of  Surgery,"  vol.  11. 

"  Med.-Chir.  Trans.,"  vol.  xiv. 


In  Whose  Possession. 


Adams. 

Adler. 

Goyrand. 

Brulatour. 

Guy's  Hospital  Museum. 


Van  Houte. 

Chelius. 

Soemmering' s  collection. 


Fawcington.' 

Field. 

Pathologic  Museum,Breslau. 

Ponfick. 

Geddings. 

Giessen  Museum. 

Hamilton. 

Harris. 

St.  George's  Hospital, 
Specimen  No.  112. 
Howship. 


BONY    UNION. 


447 


TABULATED   SPECIMENS   OF   BONY   UNION   AFTER   INTRACAPSULAR 
FRACTURE.— ( Continued. ) 


No. 


Name  of 
Reporter. 


Where  Mentioned  or  Classified. 


In  Whose  Possession. 


22 

23 

24 

25 
26 

27 
28 

29 

30 
31 
32 
33 
34 
35 
36 

37 


42 


49 
50 
SI 
52 
53 


Hutchinson, 
Hutchinson, 

Jones, 

Kocher, 

Kroenlein, 

Langstaff, 

Maas, 

Malgaigne, 

March, 

March, 

March, 

Mussey, 

Mussey, 

Mussey, 

Parker,  W., 

Pope, 


38  1  Post, 

39  Riedinger, 

40  Roberts, 

41  Sands, 


Selden, 


43  Selden, 

44  Senn, 

45  Smith,  H.  H., 
I 

46  Smith,  H.H 

47 


55 


Smith,  R.W., 
Smith,  R.W., 
South, 

South, 

Spalding, 

Stanley, 


Swan, 
54     Zeiss, 


Zeiss, 


"Illustr.  Clin.  Surgery,"  vol.  II,  p.  8. 
"Museum  Notes"  of  Jan.  23,  1870. 

"Med.-Chir.  Trans.,"  vol.  XXIV. 
Personal  communication. 
Personal  communication. 
"  Med.-Chir.  Trans.,"  vol.  XIII. 
Personal  communication. 

"A  Treatise  on  Fractures,"  1859,  p. 

555- 
"Trans.  Am.  Med.  A.ssoc,"  1858. 
"Trans.  Am.  Med.  Assoc,"  1858. 
"Trans.  Am.  Med.  Assoc,"  1858. 
"Am.  Jour.  Med.  Sci.,"  1857,  p.  299. 
"Am.  Jour.  Med.  Sci.,"  1857,  p.  299. 
"Am.  Jour.  i\Ied.  Sci.,"  1857,  p.  290. 
Johnson,   "Intracapsular  Fractures," 

1857,  p.  28. 
Hamilton  on  "  Fractures,"  p.  407. 
Personal  communication. 

"Studien  iiber  Grund  u.  Einkeilung 
derSchenkelhalsbruche,i874,  PI.  xi. 
Personal  communication. 
"New  York  Med.  Record,"  June  I, 

1869. 
"Trans.  Yirginia  State   Med.  Soc," 

1877. 
"Trans.  Virginia  State  Med.  Soc," 

1877. 
"Trans.  Am.  Surg.  Assoc,"  1883. 
"  Princ.  and  Prac  of  Surg.,"  vol.  II, 

p.  610. 
"Princ  and  Prac.  of  Surg.,"  vol.  II, 

p.  610. 
"  Dublin  Jour.  Med.  Sci.,"  Jan.,  1873. 
"  Dublin  Jour.  Med.  Sci.,"  Jan.,  1873. 
Chelius  "Surgery,"  by  South,  vol.  I, 

p.  621. 
Quoted  by  Hamilton,  ed.  1871,  p.  363. 

"Boston  Med.  and  Surg.  Jour.," 
March  4,  1858. 

"Med.-Chir.  Review,"  vol.  Xll,  p. 
170. 

"On  Diseases  of  Nerves,"  p.  304. 

Hamilton,  "  Fractures  and  Disloca- 
tions," 1880,  p.  406. 

Hamilton,  "  Fractures  and  Disloca- 
tions," 1880,  p.  406. 


Leeds  Hospital  Museum. 

Museum  of  Trinity  College, 
Dublin. 

Jones. 

Pathologic  Museum,  Berne. 

Pathologic  Museum,  Zurich. 

Langstaff. 

Pathologic  Museum,  Frei- 
burg. 

Musee  Dupuytren. 

Albany  College  Museum. 

Albany  College  Museum. 

Albany  College  Museum. 

Mussey. 

Mussey. 

Mussev. 

\V.  Parker. 


Destroyed    in    fire    of  Uni- 
versity Medical  College. 
Wiirzburg  Museum. 

Penna.  Hospital  Museum. 
Sands. 

Selden. 

Selden. 

Army  Medical  Museum. 
\Vister  and  Horner  Museum. 

Smith. 

Trinity  College  Museum. 
Trinity  College  Museum. 
South. 

Museum    of    St.    Bartholo- 
mew's Hospital. 
Spalding. 

Stanley. 

Swan. 
Zeiss. 

Zeiss. 


Only  a  description  will  be  given  here  of  a  few  undoubted  speci- 
men.s,  for  the  purpose  of  illustrating  the  alterations  that  occur  in 
the  femoral  neck  during  the  process  of  repair. 

R.  Adams  (No.  i  in  table)  :  "  The  round  ligament  was  sound. 
The  head  and  neck  of  the   bone   had  lost  their  normal  obliquity 


448 


SPECIAL    FRACTURES. 


and  were  directed  nearly  horizontally  inward  ;  the  cervix  presented, 
both  anteriorly  and  posteriorly,  evidence  of  a  transverse  intracap- 
sular fracture  having  occurred.  The  globule-shaped  head  was 
closely  approximated  behind  and  below  to  the  posterior  intertro- 
chanteric line  and  to  the  lesser  trochanter,  so  that  the  neck  seemed 
altogether  lost,  except  anteriorly,  where  a  well-marked  ridge  of 
bone  showed  the  seat  of  displacement  and  of  the  union  of  the 
fragments.  This  ridge  is  evidently  the  upper  extremity  of  the 
lower  fragment  of  the  cervix.  The  fracture  of  the  neck  posteriorly 
was  found  to  have  been  closer  to  the  corona  of  the  head  than 
anteriorly,  and  the  fibrosynovial  fold  in  the  former  situation  re- 
mained unbroken.     A  section  has  been  made  of  the  bone  through 


/' 


~\ 


Fig.  278. — Posterior  view  of  bony 
union  after  fracture  of  neck  of  femur 
(Hutchinson). 


Fig.  279. — Vertical  section  showing 
bony  union  after  fracture  of  neck  of  femur 
(Hutchinson). 


the  head,  neck,  and  trochanter  ;  one  portion  has  been  subjected  to 
maceration  and  boiling,  and  the  bony  union  has  been  unaffected 
by  these  tests.  Scarcely  any  portion  of  the  neck  can  be  said  to 
have  been  left.  The  section  shows  the  compact  line  that  denotes 
the  union  of  the  fragments ;  the  head  and  shaft  seem  to  be 
mutually  impacted  into  each  other,  and  almost  the  entire  cervix 
has  been  absorbed  ;  the  line  of  union  is  serrated,  solid,  and  immov- 
able ;  the  cells  of  the  head  and  substance  of  the  shaft  seem  to 
communicate  freely  in  all  places,  except  where  the  thin  line  of 
compact  tissue  here  and  there  points  out  the  seat  of  the  welding 
together  of  the  remaining  portions  of  the  head  and  neck  of  the 
femur." 


BONY    UNION. 


449 


As  Mr.  Adams,  in  his  article  on  "  Abnormal  Conditions  of  the 
Hip-joint  "  in  Todd's  "  Encyclopedia,"  took  the  ground  that  bony 
union  was  impossible,  and  commented  unfavorably  on  the  cases  that 
had  been  reported  as  instances  of  bony  consolidation,  it  is  evident 
that  this  case  must  have  presented  convincing  proof  in  order  to 
change  his  views  on  this  subject.  The  value  of  this  specimen  is 
enhanced  by  a  full  and  clear  clinical  history. 

Chorley's  specimen,  described  by  Jonathan  Hutchinson  (No. 
22  in  table)  :  "  The  bone  which  supplied  the  illustration  I  now  pub- 
lish is  one  of  the  many  treasures  of  the  Pathologic  Museum  of 
the  Leeds  Hospital.  The  drawings  were,  by  permission,  made  for 
me  by  Mr.  Tuffen  West, 
some  years  ago,  at  the 
time  of  the  visit  of  the 
British  Medical  Associa- 
tion to  Leeds.  The  spe- 
cimen is  the  best  example 
of  union  of  an  intracapsular 
fracture  with  which  I  am 
acquainted,  and  as  it  ap- 
pears to  be  beyond  all 
cavil,  I  have  great  pleasure 
in  endeavoring  to  secure 
for  it  a  wider  recognition. 
The  drawings  show  so  ex- 
actly the  condition  of  the 
bone  that  it  is  scarcely 
necessaiy  to  describe  them. 
It  will  be  seen  that,  while 
the  transverse  fracture  is 
wholly  within  the  capsule, 
and  nowhere  more  than 
half  an  inch  from  the  ar- 
ticular head,  yet  on  the 
back  of  the  cervix  some 
fragments  have  been  de- 
tached   which    pass    much 

further  out.  It  is  worth  notice,  also,  that  in  the  section  of  the 
bone  the  edge  of  the  lower  outer  layer  is  seen  to  catch  in  the 
cancellous  tissue  of  the  articular  end,  thus  constituting  a  degree  of 
imi)action  which,  no  doubt,  much  favored  fixation  and  union.  The 
specimen  was  obtained  by  the  late  Mr.  Chorley,  formerly  surgeon 
to  Leeds  Infirmary,  from  the  body  of  a  gentleman  aged  seventy, 
whom  he  had  attended  several  years  before  his  death,  with  the 
diagnosis  of  fracture  of  the  neck  of  the  thigh  bone.  The  treat- 
ment had  been  by  very  careful  immobilization  and  long-continued 
confinement  to  bed.  The  recovery  had  been  such  that  the  patient 
had  been  able  to  walk  well  with  a  stick." 
29 


Fig.  280. — Anterior  view  of  bony  union  after  in- 
tracapsular fracture  (Riedinger). 


450 


SPECIAL    FRACTURES. 


The  well-known  ability  of  Mr.  Hutchinson  is  a  sufficient  guar- 
anty for  the  genuineness  of  this  specimen. 

Riedinger's  specimen  (No.  39  in  table)  :  The  neck  of  the  femur 
is  considerably  shortened,  and  the  head  inclines  so  far  backward 
that,  superiorly,  it  comes  almost  completely  in  contact  with  the 
posterior  intertrochanteric  line.  From  behind,  only  the  cartilag- 
inous surface  of  the  head  can  be  seen  ;  downward,  the  neck  is 
visible  to  the  extent  of  i  cm.  ;  above,  the  length  of  the  neck  is  i  ^ 
cm.  On  the  anterior  surface  the  well-marked  denticulated  line  of 
fracture  can  be  seen  close   to   the   head.      Its  length  is  3  cm.     A 

longitudinal  section 
of  the  upper  portion 
of  the  femur  into  an 
anterior  and  a  pos- 
terior half  discloses 
the  line  of  fracture 
in  the  loosely  can- 
cellated tissue  of 
the  spongiosa,  and 
more  clearly  shows 
the  impaction  of  the 
lower  fragment  into 
the  head,  which  is 
especially  well 
marked  in  the  lower 
cortical  portion  of 
the  neck  (Adams' 
arch).  The  length 
of  the  implanted 
portion  amounts  to 
2  cm. 

As  Riedinger 
has  made  fractures 
of  the  neck  of  the 
femur  a  special 
study  for  many 
years,  no  one  would  for  a  moment  doubt  the  correctness  of  his 
description  or  the  authenticity  of  this  specimen. 

Gurlt's  specimen  (No.  1 7  in  table)  :  "  The  fracture  runs  obliquely 
through  the  neck  of  the  femur  ;  in  front  it  is  three-fourths  of  an 
inch  from  the  base  of  the  neck  ;  posteriorly,  a  little  less.  The 
head  of  the  bone  is  displaced  somewhat  backward  and  downward 
and  is  united  by  bone,  although  the  line  of  fracture  is  still  visible  in 
pkces"  (Figs..  283  and  284). 

Gurlt's  name  occupies  a  foremost  position  among  writers   on 
fractures,  present  and  past,  and  his  decision  admits  of  no  appeal. 
To  prove  the  validity  of  any  specimen,  it  is  necessary  to  examine 


Fig.  281. — Posterior  view  of  bony  union  after  intracapsular 
fracture  (Riedinger). 


BONY    UNION. 


451 


for  evidences  that  will  warrant  an  afifirmative  reply  to  the  following 
questions  : 

1.  Has  the  bone  been  fractured? 

2.  Was  the  fracture  within  the  capsular  ligament  ? 

3.  Has  the  fracture  consolidated  by  bone  ? 


Fig.  282. — Vertical  section,  showing  impaction  with  bony  union  after  intracapsular 
fracture  (Riedinger). 


Fig.  283. — Anterior  view  of  bony  union  Fig.  284. — Section  through  neck,  .showing 

after  intracapsular  fracture  ((Jurlt).  bony  union  within  capsule  (Gurlt). 


The  first  question  can  ari.se  only  in  specimens  without  a  clinical 
history.      Postmortem    specimens    have   been   brought  forward   as 


452 


SPECIAL    FRACTURES. 


instances  of  bony  union,  when  the  changes  in  the  bone  were 
due  to  other  causes,  as  rickets  and  senile  coxitis.  In  all  cases  of 
interstitial  absorption  without  fracture  the  wasting  of  the  neck 
takes  place  in  a  more  symmetric  manner  ;  the  neck  may  become 
greatly  shortened,  and,  yielding  to  the  vertical  pressure,  the  head 
may  descend  to  a  level  with  the  upper  border  of  the  trochanter 
major,  but  does  not  incline  backward,  as  is  generally  the  case  when 
fracture  has  taken  place.  In  senile  coxitis  the  head  is  enlarged, 
and  presents  the  characteristic  deep  depression  for  the  round  liga- 
ment ;  at  the  same  time  its  upper  and  anterior  surface  is  deprived 
of  cartilage,  and  presents  an  eburnated  appearance  (Fig.  285). 
If    rickets    or    senile    osteomalacia    has    been    the    cause    of    the 

deformity,  the  disease  af- 
fects both  joints  simulta- 
neously. An  intracapsular 
fracture  always  unites  with 
some  degree  of  deformity. 
Longitudinal  sections  of 
the  specimens  usually  dis- 
close the  direction  and  ex- 
tent of  displacement  of  the 
fragments.  From  causes 
that  have  been  previously 
enumerated,  absorption  of 
the  neck  is  more  extensive 
in  the  posterior  portion  of 
the  neck  than  in  the  ante- 
rior, permitting  the  head  to 
approach  the  posterior  in- 
tertrochanteric ridge.  If 
the  fracture  has  been  en- 
tirely wathin  the  capsule, 
little  or  no  provisional  cal- 
lus is  found  over  the  seat 
of  the  fracture,  while  in  senile  coxitis  irregular  bony  masses  are 
found  over  different  portions  of  the  neck. 

The  writer  on  fracture  of  the  neck  of  the  femur  in  Eulenburg's 
"Encyclopedia"  says:  "If  bony  union  takes  place,  the  femoral 
neck  disappears  almost  completely  by  absorption,  the  head  coming 
nearly  in  contact  with  the  trochanteric  region.  Little  or  no  callus 
is  found  upon  the  surface  of  the  neck."  These  changes  are  shown 
most  admirably  in  the  author's  specimen. 

Bardeleben  indicates  the  following  appearances  as  characteristic 
of  union  by  bone  after  fracture  within  the  capsule  :  "  If  it  can  be 
ascertained  with  certainty  that  a  fracture  has  occurred  during  life, 
and  on  postmortem  we  find  a  bone  cicatrix, — that  is,  a  disc  of 
dense  bone  through  the  intracapsular  portion  of  the  neck, — and  if 
there  are  no  other  evidences  of  synovitis  or  osteitis,  then  we  are 


Fig.    285. — Appearance   of  head  and  neck  of 
femur  in  senile  coxitis  (Richardson). 


BONY    UNION.  453 

justified  in  claiming  for  such  a  case  that  a  fracture  within  the  cap- 
sule has  united  by  bone." 

Erichsen  remarks  :  "  When  bony  union  has  taken  place,  the 
head  will  usually  be  found  somewhat  twisted  around,  in  such  a 
way  that  it  looks  toward  the  lesser  trochanter,  owing  to  the  ever- 
sion  that  has  taken  place  in  the  lower  fragment." 

Gurlt  states  :  "  Absorption  of  the  fragments  occurs  exclusively 
in  fractures  involving  joints,  and  proceeds  hand  in  hand  with  the 
process  of  repair.  In  some  joints,  as  in  the  hip-joint,  it  may  be  so 
extensive  that  almost  the  entire  neck  is  absorbed.  This  is  more 
likely  to  be  the  case  if  the  fracture  is  within  the  capsule.  In  such 
cases  the  head  of  the  bone  may  be  very  near  the  greater  trochanter, 
at  the  base  of  the  cervix  femoris.     The  cause  of  this   absorption 

is  not  known."  . 

The  characteristic  deformity  presented  by  specimens  ot  bony 
union  of  fracture  through  the  neck  of  the  femur  corresponds  to 
the  direction  of  the  displacing  forces— shortening  and  eversion. 
The  cause  of  the  primary  displacement  is  the  fracturing  torce  itself. 
The  secondary  displacement  takes  place  upon  the  accession  of 
osteoporosis,  and  is  the  result  of  softening  and  absorption  of  bone, 
muscular  contraction,  and  the  force  of  gravitation. 

Exacting  critics   have  questioned  the  validity  of  many  speci- 
mens of  bony  union,  on  the  ground  that  the  fracture  was  not  en- 
tirely  intracapsular.      Indeed,   this   argument   has   been   the   main 
support  of  all  modern  believers  in  nonunion.      In  all  specimens  of 
bony  union  the  point  of  attachment  of  the  posterior  portion  of  the 
capsular  ligament  is  changed  :  instead  of  being  inserted  near  the 
middle  of  the  femoral  neck,  it  is  found  attached  to  or  near  the  pos- 
terior intertrochanteric  line,  and  on  this  account  it  has  been  asserted 
that  the  fracture  extended  beyond   the  capsular  ligament.     It  is 
however,  more  probable  that  this  alteration  in  the  attachment  of 
the  capsule  admits  of  a  more  satisfactory  explanation.      AH  frac- 
tures are  followed  by  osteoporosis  in  the  ends  of  the  broken  bone, 
and  this  is  more  especially  well  marked  in  intra-articular  fractures. 
During  the  osteoporotic  process  the  periosteal  covering  of  the  bone 
is  loosened,  and  readily  changes  its  relative  position  to  the  bone 
during  the    process   of  interstitial   absorption,   and   carries  with  it 
the  capsular  ligament  with  which  it  is  intimately  connected.      In- 
terstitial absorption  precedes  and  attends  the  production  of  callus, 
and  is  most  active  in  that  portion  of  the  bone  supplied  with  the 
greatest    number    of    blood-vessels.     The    upper  fragment    being 
scantily  supplied  with  blood-vessels,  absorption,  if  it  takes  place  at 
all    occurs  at  a   later  date  and  progresses  very  slowly,  while  the 
reverse  is  the  case  in  the  lower  fragment.     The  point  of  attach- 
ment of  the  capsular  ligament  is  no  indication  as  to  the  seat  of 
fracture  as  almost  the  entire  femoral  neck  may  disappear  by  ab- 
sorption, and  the  capsule  approaches  the  trochanteric  region  m  pro- 
portion to  the  amount  of  bone  absorbed.      A  more  important  sign 


454 


SPECIAL    FRACTURES. 


is  the  presence  or  absence  of  new  bone  upon  the  outside  of  the 
capsule.  In  intracapsular  fractures  little  or  no  external  callus  is 
produced  within  or  without  the  capsule,  while  extracapsular  frac- 
tures, for  obvious  anatomic  reasons,  yield  an  abundance  of  exuber- 
ant callus,  part  of  which  at  least  remains  permanently.     The  last 

test  is  to  ascertain  the  nature  of 
the  connecting  medium.  This  can 
be  done  by  submitting  the  specimen 
to  a  microscopic  examination  or  to 
the  boiling  process.  In  the  first  test 
the  tissues  at  the  seat  of  fracture  will 
show  the  histologic  elements  of  true 
bone  in  all  genuine  specimens.  The 
boiling  process  will  destroy  the  liga- 
mentous union  between  the  fragments 
in  all  doubtful  cases,  and  is,  therefore, 
the  simplest  and  most  certain  method 
of  demonstrating  the  restoration  of 
the  continuity  of  the  broken  bone. 

In  recapitulation  it  may  be  stated 
that  the  validity  of  a  specimen  is 
established  whenever  the  clinical  his- 
tory has  revealed  the  existence  of 
fracture  during  life,  and  the  postmor- 
tem examination  has  demonstrated 
that  the  fracture  has  been  within  the 
capsule  and  that  the  union  is  by 
bone. 
Nonunion  after  Intracapsular  Fractures. — Sir  Astley  Cooper 
enumerates  the  causes  of  nonunion  under  the  following  heads  : 

1.  Want  of  proper  apposition  of  the  bones. 

2.  Want  of  pressure  of  one  extremity  of  the  broken  neck  upon 
the  other,  even  though  the  limb  preserved  its  length,  and  the  frac- 
tured parts  are  consequently  not  much  displaced. 

3.  Absence  of  nutrition  in  the  head  of  the  thigh  bone. 

4.  Atrophy  of  bone. 

The  first  cause  can  only  apply  to  nonimpacted  fractures  where 
treatment  has  failed  to  keep  the  fractured  ends  in  immediate  and 
uninterrupted  contact  for  a  sufficient  length  of  time  for  union  by 
bone  to  take  place,  and  as  such  constitutes  the  principal,  if  not  the 
only,  cause  of  nonunion.  There  is  no  other  fracture  where  immo- 
bilization is  so  difficult  to  accomplish.  Every  movement  of  the 
body  disturbs  the  fractured  ends.  No  apparatus  yet  devised  has 
answered  the  first  and  principal  indication  in  the  treatment  of  all 
fractures — namely,  to  secure  perfect  immobility  and  permanent  co- 
aptation. 

Colles,  who  fully  indorses  the  views  of  Sir  Astley  Cooper  on 
the  subject  of  fractures  within   the   capsule,  in  speaking   of   the 


Fig.  286. — Impacted  fracture 
of  the  neck  of  the  femur  at  its  base, 
exhibiting  a  massive  extra-articular 
callus.     Lateral  view  (after  Verity). 


NONUNION    AFTER    INTRACAPSULAR    FRACTURES.  455 

causes  of  nonunion  remarks  :  "  However  this  may  be,  I  think  the 
difficulty  of  keeping  the  parts  motionless  on  each  other  would  be 
sufficient  of  itself  to  account  for  it." 

Gurlt,  who  has  studied  the  process  of  repair  in  fractures  with 
the  most  assiduous  care,  saj's  :  "  There  is  no  specific  tendency  to 
nonunion  in  any  form  of  fracture.  If  the  ends  of  the  broken  bones 
can  be  kept  in  accurate  apposition,  union  by  bone  will  take  place." 
As  illustration  of  this  statement  he  mentions  the  following  frac- 
tures :  Neck  of  femur,  patella,  coronoid  process  of  inferior  maxilla, 
coracoid  process  of  scapula,  olecranon,  coronoid  process  of  ulna, 
trochanter  major,  tuberosity  of  os  calcis,  spinous  processes  of 
vertebrae,  and  some  of  the  sharp  prominences  of  the  pelvic  bones. 

The  second  cause  of  nonunion — want  of  pressure  of  one 
fragment  upon  the  other — implies  a  want  of  apposition  expressed 
in  other  words.  Dupuytren  and  Brainard  were  of  the  opinion  that 
oblique  fractures  resulted  more  frequently  in  nonunion  than  trans- 
verse fractures,  and  Dupuytren  applied  this  rule  to  fractures  of  the 
neck  of  the  femur.  Experience  has  shown  that  of  all  fractures 
within  the  capsule,  none  is  so  prone  to  result  in  nonunion  as 
transverse  fractures  through  the  narrowest  portion  of  the  neck. 
Lateral  pressure  applied  over  the  trochanter  major  is  an  important 
measure  for  obtaining  union  by  bone,  but  this  desirable  result  does 
not  follow  from  the  fact  that  pressure  is  made,  but  simply  because, 
by  the  pressure,  coaptation  and  immobilization  are  effected. 

Deficient  vascular  supply  of  the  upper  fragment  is  prominently 
mentioned,  by  almost  every  author,  as  against  the  probability  of 
union  by  bone.  On  the  other  hand,  it  is  generally  admitted  that  frac- 
tures of  the  anatomic  neck  of  the  humerus  unite  by  bone,  and  that 
completely  isolated  pieces  of  bone,  when  properly  replanted  or  trans- 
planted, retain  their  vitality  and  physiologic  properties.  It  is  also 
well  known  that  traumatic  or  pathologic  epiphyseolysis  may  be 
repaired  by  bony  callus.  Why  should  the  upper  fragment  in  intra- 
capsular fractures,  with  at  least  a  doubtful  supply  of  blood  through 
the  round  ligament,  make  an  exception  to  this  general  rule  ?  Simply 
because,  in  this  instance,  coaptation  without  impaction  is  next  to 
impossible  with  the  present  methods  of  treatment.  On  this  point 
MacNamara  makes  this  statement :  "I  hardly  think  the  nonunion 
between  the  ends  of  the  bone  in  instances  of  intracapsular  fracture 
of  the  neck  of  the  femur  is  most  frequently  due  to  the  insufficient 
blood  supply  of  the  head  of  the  bone  ;  otherwise  we  should  more 
commonly  meet  with  examples,  after  fractures  of  this  kind,  in  which 
the  head  of  the  bone  had  become  absorbed  ;  but,  as  you  will  see  in 
the  specimen  I  now  show  you,  the  cancellated  tissue  of  the  head  of 
the  bone  is  supplied  with  blood  through  vessels  passing  along  the 
round  ligament  and  through  the  fibrous  structure  uniting  it  with  the 
trochanter  major." 

The  fractured  head  of  the  humerus,  deprived  of  all  vascular 
supply,  unites  by  bone  as  any  other  fracture,  because  the  anatomic 


456  SPECIAL    FRACTURES. 

relations  about  the  seat  of  fracture  are  such  that  coaptation  is 
maintained  without  difficulty,  and  fractures  within  the  capsule  of 
the  hip-joint  will  follow  the  same  rule  as  soon  as  the  surgeon  can 
successfully  combat  the  obstacles  that  cause  displacements. 

The  last  cause,  atrophy  of  bone,  is  the  weakest  argument  in 
favor  of  nonunion.  Clinical  experience  furnished  abundant  proof 
that  in  persons  suffering  from  fragilitas  ossium,  regardless  of  its 
cause,  fractures  not  only  unite,  but  unite  very  promptly.  Mr. 
Holmes,  in  his  "System  of  Surgery,"  quotes  from  Gibson  the  case 
of  a  youth  of  nineteen  who  had  24  fractures,  and  from  Esquirol 
another  with  as  many  as  200  fractures.  Earle  records  a  case  of  8 
fractures  in  a  child  of  ten  years,  and  Flemming  observed  a  case 
where  a  person  suffered  53  fractures  between  the  ages  of  one  and 
one-half  and  twenty-five  years.  In  all  these  cases  union  took 
place  rapidly. 

Gurlt  reports  a  large  number  of  similar  cases.  He  states  very 
distinctly  that  old  age  does  not  retard  the  process  of  union,  as  lias 
been  erroneously  supposed :  the  reparative  process  remains  the  same  as 
during  adidt  life.  Nonunion  of  fractures  is  seen  more  frequently 
in  the  adult  than  in  the  aged.  I  have  seen  a  fracture  of  the  femur, 
at  the  junction  of  the  middle  with  the  upper  thu'd,  in  an  old, 
decrepit  man  suffering  at  the  same  time  from  locomotor  ataxia, 
unite  firmly  by  bone  in  less  than  six  weeks.  Fracture  of  the  lower 
end  of  the  radius  is  common  after  middle  life,  and  invariably  unites 
in  a  remarkably  short  time.  Senile  osteoporosis  is  a  condition  of 
bone  favorable  to  the  production  of  intermediate  callus.  Atrophy 
of  bone  facilitates  osteoporosis,  an  event  that  always  precedes  the 
formation  of  callus. 

Some  authors  mention  still  other  causes  of  nonunion,  as  the 
presence  of  synovia  and  the  absence  of  a  nidus  for  the  formative 
material.  Both  of  these  conditions  remind  us  simply  that  the  frac- 
tured ends  are  not  in  apposition  ;  otherwise  they  have  no  signifi- 
cance in  preventing  union  by  bone. 

From  this  short  review  we  are  not  only  justified,  but  warranted, 
in  asserting  that  the  only  cause  for  nonunion  in  cases  of  intracap- 
sular fracture  is  to  be  found  in  our  inability  to  maintain  perfect 
coaptation  and  immobilization  of  the  fragments  during  the  time 
required  for  bony  union  to  take  place. 

Bony  Union  after  Intracapsular  Fractures. — In  a  circular 
letter  addressed  by  me  in  1883  to  prominent  surgeons  in  this  coun- 
try, England,  France,  Germany,  and  Switzerland,  for  the  purpose  of 
ascertaining  the  prevailing  opinion  on  the  subject  of  bony  union 
after  intracapsular  fractures,  this  question  was  propounded:  "  In  your 
opinion  does  bony  union  ever  occur  after  impacted  intracapsular 
fracture  of  the  neck  of  the  femur,  and  under  what  circumstances  ?  " 

To  this  question  fifty  direct  replies  were  received.  The  opinions 
were  divided  as  follows  :  Yes,  27  ;  no,  18  ;  doubtful,  5.  It  is  a 
significant  fact  that  the  replies  from  professors  of  surgery  in   Ger- 


BONY  UNIOX  AFTER  INTRACAPSULAR  FRACTURES.       45/ 

man  universities,  five  in  number,  were,  without  exception,  in  the 
afiirmative,  while  the  greatest  diversity  of  opinion  appeared  to  exist 
in  our  own  country  ;  at  least  50  per  cent,  of  the  correspondents 
replied  with  an  emphatic  "  no."  The  answers  received  undoubtedly 
reflect  correctl)-  the  sentiments  of  the  entire  profession  on  this 
point.  If  we  add  the  five  doubtful  correspondents  to  the  eighteen 
negative,  we  have  nearly  50  per  cent,  who  do  not  believe  it  possible 
for  bony  union  to  take  place  within  the  capsule  even  under  the  most 
favorable  circumstances. 

The  text-books  and  monographs  on  this  subject  were  consulted 
Avith  about  the  same  result.  It  would  then  appear  that  nearly  one- 
half  of  the  profession  still  doubt  the  possibility  of  union  by  bone 
in  cases  of  intracapsular  fractures. 

Having  shown  that  there  are  no  anatomic  and  physiologic  im- 
possibilities present  to  prevent  osseous  union  after  intracapsular 
fractures,  and  having  referred  to  a  number  of  reliable  and  well- 
authenticated  cases  of  this  kind,  the  opinion  on  this  subject  of  a 
few  recognized  authorities  will  be  quoted. 

Sir  Astley  Cooper,  the  originator  of  the  controversy  on  this 
subject,  and  who  is  always  quoted  as  authority  on  the  negative 
side  of  this  question,  never  denied  the  possibility  of  union  by  bone, 
as  is  evident  from  what  he  says  on  page  137  of  his  work  :  "I 
have  only  met  with  one  in  which  a  bony  union  had  taken  place,  or 
which  did  not  admit  of  a  motion  of  one  bone  upon  the  other. 
To  deny  the  possibility  of  this  union  (bony  union)  and  to  maintain 
that  no  exception  to  the  general  rule  can  take  place  would  be  pre- 
sumptuous, especially  when  we  consider  the  varieties  of  direction 
in  which  a  fracture  may  occur,  and  the  degree  of  violence  by  which 
it  may  have  been  produced." 

He  enumerates  a  number  of  conditions  that  would  maintain 
permanent  apposition,  and  then  proceeds  :  "  Such  a  favorable  com- 
bination of  circumstances  is  of  very  rare  occurrence."  At  the 
time  this  was  written  the  process  of  repair  in  bone  was  but  imper- 
fectly undenstood,  and  the  occurrence  of  impaction  within  the  cap- 
sule was  either  unknown  or  its  importance  as  an  essential  element 
for  bony  union  was  not  appreciated. 

Heistcr,  nearly  a  century  and  a  half  ago,  after  explaining  that 
the  frequency  of  nonunion  in  cases  of  fractures  of  the  femoral 
neck  was  owing  to  the  difficulty  of  keeping  the  broken  ends  of  the 
bone  in  aj^position,  made  the  following  statement :  "  If  an  instru- 
ment could  be  invented  which  would  keep  such  a  limb  so  extended 
that  during  the  cure,  or  at  least  during  the  first  two  or  three  weeks, 
it  could  be  kept  as  long  as  the  healthy  one,  there  would  be  hope 
that  the  fracture  could  be  cured  more  satisfactorily  than  has  been 
the  ca.se  heretofore."  Since  we  have  learned  that  the  production 
of  the  intermediate  callus  requires  months  instead  of  weeks,  Heister 
would  have  to  modify  his  statement  by  greatly  extending  the  time 
required  for  maintaining  apposition. 


AcS  SPECIAL    FRACTURES. 

Desault,  in  combating  the  popular  idea  of  insufficient  blood 
supply  as  a  cause  of  nonunion,  states  :  "  The  head  of  the  bone, 
separated  from  the  soft  parts  and  attached  to  the  acetabulum  by 
the  round  ligament,  receives  a  sufficiency  of  nutriment  to  enable  it 
to  live  in  that  cavity,  for  there  is  no  instance  of  its  having  suffered 
mortification  in  consequence  of  a  fracture.  Why,  then,  should  it 
not  partake  of  the  properties  of  Hfe,  and  particularly  of  the  faculty 
of  reunion,  when  placed  in  regular  apposition  with  the  body  of  the 

bone?  " 

The  following  quotation  is  from  Syme  :  "  But  none  of  the  argu- 
ments which  have  been  adduced  to  prove  the  impossibility  of  osse- 
ous junction  seems  to  be  conclusive,  and  though  the  small  extent 
and  mobility  of  the  broken  surfaces,  the  absence  of  vascular  tissues 
surrounding  the  fracture,  and,  perhaps,  also  the  presence  of  syno- 
vial fluid  may  render  the  cure  very  difficult,  it  ought  still  to  be 
regarded  as  a  possible  occurrence." 

Richter  claimed  that  bony  union  could  take  place  in  impacted 
fractures,  or  where,  by  careful  treatment,  apposition  and  retention 
were  fully  accomplished.  He  evidently  was  impressed  with  the 
importance  of  the  bone -producing  function  of  the  periosteum,  as 
he  advanced  the  theory  that,  in  fractures  of  the  neck  with  complete 
rupture  of  the  periosteum,  under  favorable  conditions,  bridges 
could  be  thrown  across  the  line  of  fracture  from  one  membrane  to 
the  other,  from  which  bone  could  be  produced. 

Dupuytren,  in  criticizing  the  treatment  adopted  by  the  English 
surgeons,  and  alluding  to  the  secondary  displacements  owing  to 
the  too  early  removal  of  retaining  apparatus,  makes  the  following 
remark  :  "  But  if  these  surgeons  had  adopted  the  practice  of  the 
Hotel  Dieu  in  keeping  their  patients  in  bed  for  eighty  or  even  a 
hundred  days,  they  would  have  been  convinced  of  the  practicability 
of  reunion  and  complete  cure  without  deformity."  And,  again  : 
"  I  can  only  say,  for  my  part,  that  if  the  specimens  at  the  Hotel 
Dieu  are  insufficient  to  satisfy  any  one  who  may  take  the  trouble 
to  examine  them,  I  am  at  a  loss  to  know  what  amount  of  evidence 
such  skeptics  would  require.  For  my  part,  I  regard  the  osseous 
union  of  intracapsular  fractures  as  demonstrated  and  placed  beyond 
doubt." 

Malgaigne  is  a  firm  exponent  of  Sir  Astley  Cooper's  teachings, 
and  yet,  after  the  most  critical  examination  of  specimens  for  which 
bony  union  was  claimed,  he  is  forced  to  acknowledge  that  three  of 
them  were  genuine.  He  says  :  "When  a  fracture  unites,  the  frag- 
ments do  not  undergo  such  enormous  losses  of  substance  as  we 
should  be  forced  to  admit  in  the  neck  of  the  femur  ;  and  in  Swain's 
case,  which  Sir  Astley  Cooper  himself  acknowledged  as  an  instance 
of  bony  union,  the  neck  of  the  bone  had  not  changed  its  form.  It 
was  so  also  in  Stanley's  case  ;  and,  lastly,  one  femur  (No.  i88)  in 
the  Musee  Dupuytren  has  lost  riothing,  either  in  form  or  volume, 
except  as  the  result  of  very   trifling   displacement.      I  admit  that 


BONY  UNION  AFTER  INTRACAPSULAR  FRACTURES.       459 

these  three  examples  demonstrate  quite  positively  the  existence  of 
consolidation  ;  but  I  can  not  say  the  same  of  the  rest."  Loss  of 
substance  and  change  of  direction  of  the  neck  can  no  longer  be 
admitted  as  evidence  against  the  existence  of  bony  union,  as  they 
only  indicate  the  presence  of  impaction,  followed  by  interstitial 
absorption  the  consequence  of  osteoporosis. 

N.  R.  Smith,  in  recommending  his  anterior  splint  in  the  treat- 
ment of  fractures  of  the  neck  of  the  femur,  expresses  his  convic- 
tions as  follows:  "This  apparatus,  with  slight  modifications,  is 
applicable  to  all  fractures  of  the  femur.  To  none  is  it  more  appro- 
priate, and  in  none  has  it  accomplished  more  satisfactory  results, 
than  in  fractures  of  the  cervix,  the  events  of  which  are  so  justly 
regarded  as  an  opprobrium  of  surgery.  So  uniformly  have  non- 
union and  deformity  resulted,  that  eminent  surgeons  have  denied 
that  bony  continuity  is  ever  restored  within  the  capsule.  We  hope 
to  show  these  results  are  rather  the  consequence  of  insufficient 
treatment  than  defect  in  the  reparative  power  of  nature." 

H.  H.  Smith  advocates  the  possibility  of  bony  union  in  the 
following  language:  "That  osseous  union  has  been  seen  can  not 
reasonably  be  doubted,  and  from  a  careful  analysis  of  the  seat  of 
fracture  in  these  cases  I  think  it  is  evident  that  there  are  a  com- 
paratively limited  number  of  cases  in  which  osseous  union  does 
occur  ;  and  I  suggest  that,  as  a  general  rule,  based  on  observation, 
it  will  be  found  that  the  nearer  a  fracture  is  situated  to  the  head 
of  the  bone,  or,  in  other  words,  the  shorter  the  upper  fragment, 
the  greater  will  be  the  possibility  of  osseous  union  ;  because  the 
shorter  the  upper  fragment,  the  greater  the  chance  that  the  vessels 
which  supply  it  with  blood  through  the  round  ligament  will  be 
able  to  furnish  it  with  an  amount  of  material  sufficient  to  enable 
osseous  union  to  take  place  by  a  deposit  of  bone  from  the  Haver- 
sian canals." 

Samuel  Solly  writes  :  "  If  you  can  diagnose  that  the  fracture 
is  an  impacted  fracture  of  the  cervix,  then  you  may  with  tolerable 
confidence  predict  complete  union  and  a  sound  limb.  I  have 
shown,  by  reference  to  the  preparations  in  the  College  of  Sur- 
geons' Museum  and  also  in  our  own,  that  fractures  of  the  cervix 
within  the  capsule  will  unite,  though  not  so  frequently  as  those 
without." 

Chclius  claims  that  bony  union  may  have  been  observed  less 
frequently  in  England  than  on  the  Continent,  on  account  of  neg- 
lected treatment  in  cases  diagnosticated  as  intracapsular  fractures. 

Erichsen,  in  discussing  this  subject,  remarks  :  "  In  some  cases, 
however,  bony  union  takes  place.  This  may  happen  when  the 
cervical  ligament  remains  intact  or  when  the  fracture  is  impacted." 

Holthouse  says:  "  Bony  union  in  this  fracture  (intracapsular) 
is  rare,  and  by  some  has  been  considered  impossible  ;  but  a  suffi- 
cient number  of  undoubted  cases  have  now  been  brought  to  light, 
both  in  luircjpe  and  America,  to  place  the  fact  beyond  a  doubt." 


460  SPECIAL    FRACTURES. 

Agnew,  in  speaking  of  Astley  Cooper's  method  of  treatment 
of  intracapsular  fractures,  remarks  :  "There  have  been  recorded  a 
sufficient  number  of  cases  of  bony  union,  after  what  was  believed 
to  be  intracapsular  fracture,  to  justify  a  hope  that  some  of  the  cases 
encountered  by  the  surgeon  may  have  a  similar  termination." 

Gant  expresses  a  similar  hope  :  "  Bony  union  at  one  time,  and 
for  many  years,  thought  never  to  take  place,  does  assuredly  in 
some  rare  cases  ;  but  only,  it  would  seem,  when  the  capsular  liga- 
ment remains  entire  or  the  fragments  are  impacted,  whereby  a  due 
supply  of  blood  can  be  speedily  established." 

Mr.  Thomas  Bryant  makes  use  of  the  following  language: 
"In  the  impacted  fractures  union  ought  to  be  looked  for  if  the 
broken  fragments  are  left  alone  and  not  loosened  by  a  careless  and 
too  curious  manipulation.  In  the  purely  intracapsular  fractures 
union  may  take  place — osseous  in  many  cases,  fibrous  in  more." 

MacNamara  affirms  :  "  I  believe  if  you  can  keep  the  parts  at 
rest,  in  many  cases  of  intracapsular  fractures  union  of  the  ends  of 
the  bone  will  occur." 

Koenig  realizes  the  importance  of  impaction  in  the  reparative 
process,  as  may  be  seen  from  his  statement  that  intracapsular  frac- 
tures heal  less  frequently  by  osseous  union  than  extracapsular 
fractures,  because  they  are  less  frequently  impacted. 

Hueter,  who  classifies  fractures  of  the  neck  of  the  femur  into 
those  with  and  without  impaction,  regardless  of  the  attachment  of 
the  capsular  ligament,  lays  down  as  a  rule  that  impacted  fractures 
usually  unite  by  bony  union. 

Stimson,  in  discussing  the  subject,  advances  the  following  as 
one  of  his  arguments  in  favor  of  the  possibility  of  bony  union  : 
"  Even  if  we  disregard  all  existing  specimens  of  alleged  bony 
union,  the  possibility  of  such  union  must,  I  think,  be  admitted, 
because  of  the  demonstrated  fact  that  the  head  preserves  its  vitality 
and  has  shown  its  ability  to  produce  granulations  and  bone  :  the 
former  proved  by  the  examples  of  fibrous  union,  the  latter  by 
eburnation  or  condensation  of  its  spongy  tissue." 

The  list  of  witnesses  who  testify  to  the  possibility  of  bony 
union  after  intracapsular  fractures  can  be  closed  by  quoting  the 
last  sentences  of  Jonathan  Hutchinson's  description  of  the  speci- 
men in  the  Pathologic  Museum  of  Leeds  Hospital.  "  This  speci- 
men is  alluded  to  by  Malgaigne  and  Hamilton  as  if  it  were  of 
doubtful  validity  ;  but  neither  of  them  had  probably  seen  it.  I  can 
not  but  hope  that  the  publication  of  these  life-size  drawings  of  the 
bone  will  set  at  rest  all  skepticism  as  to  the  possible  union  of  intra- 
capsular fractures.  I  trust,  also,  that  it  may  lead  to  greater  hope- 
fulness in  the  treatment  of  these  accidents,  and  thus  to  more 
systematic  care  in  securing  coaptation." 

With  such  an  array  of  unprejudiced,  honest,  and  conscientious 
witnesses  before  us,  who  unanimously  and  most  positively  testify 
that  union  by  bone  can,  and  not  infrequently  does,  take  place,  we 


TREATMENT.  46 1 

are  no  longer  warranted  in  denying  its  possibility.  The  number 
of  well-authenticated  specimens  has  been  gradually  increasing,  and 
the  knowledge  derived  from  clinical  observation  and  experimental 
investigations  on  this  subject  during  the  last  twenty  years  can 
leave  no  further  doubt  regarding  the  production  of  bony  callus  in 
intracapsular  fractures.  In  the  interest  of  science  and  for  the 
benefit  of  the  patients  this  controversy  ought  to  be  and  must  be 
decided  in  favor  of  the  affirmative,  and  then  the  profession  will  be 
prepared  to  seek  for  measures  that  will  secure  better  results. 

Treatment. — In  no  other  fracture  are  the  indications  for  suc- 
cessful treatment  so  difficult  to  meet  as  in  fracture  of  the  neck  of 
the  femur.  Every  unprejudiced  surgeon  is  forced  to  admit  that  the 
usual  bad  result  in  these  cases  is  owing  more  to  the  inefficiency 
of  the  treatment  emplo\-ed  than  to  the  anatomicopathologic  condi- 
tions of  the  broken  bone.  The  causes  of  nonunion  are  not  to  be 
found  in  the  broken  bone,  but  in  the  difficulties  encountered  in  the 
treatment.  All  the  various  methods  of  treatment  suggested  and 
practised  have  failed  to  secure  perfect  coaptation  and  uninterrupted 
immobilization.  In  all  intracapsular  fractures  union  is  effected  by 
the  production  of  an  intermediate  callus  from  the  broken  surfaces. 
Nature's  splint,  the  external  callus,  for  well-known  anatomic  reasons 
is  always  wanting,  hence  the  surgeon's  splint  has  a  more  important 
and  prolonged  application  than  in  fractures. 

The  time  required  for  bony  union  to  take  place  in  fractures  of 
the  femoral  neck  is  an  unusually  long  one.  Gurlt  fixes  the  time 
at  from  fifty-six  to  two  hundred  and  seven  days,  and  the  average 
duration  at  eighty-four  days.  Dupuytren  estimates  the  time  at 
from  one  hundred  to  one  hundred  and  twenty  days,  and  states  that 
it  had  been  customary  at  the  Hotel  Dieu  to  keep  these  patients  in 
bed  for  from  eighty  to  one  hundred  days.  There  can  be  no  doubt 
that  many  cases  that  promised  well  from  the  beginning  termin- 
ated badly  from  abandoning  the  treatment  too  early.  It  has  not 
been  an  unusual  occurrence  suddenly  to  find,  for  want  of  proper 
precautions,  at  the  end  of  the  third  or  the  fourth  week  a  rapid  in- 
crease of  shortening  from  half  an  inch  to  an  inch  and  a  half  or  even 
more.  To  prevent  secondary  displacements,  the  retentive  apparatus 
should  not  be  removed  for  at  least  from  eighty  to  one  hundred 
days. 

In  deciding  upon  a  course  of  treatment  to  be  pursued,  it  is 
important  to  make  a  distinction  between  impacted  and  nonimpacted 
fractures.  In  impacted  fractures  the  fragments  have  been  placed 
in  the  best  possible  condition  for  bony  union  to  take  place,  and  the 
sole  object  of  treatment  consists  simply  in  maintaining  the  mutual 
penetration  until  the  reparative  process  is  completed  and  the  con- 
tinuity of  the  bone  restored.  The  physician  must  be  satisfied  with 
securing  consolidation  of  the  broken  bone  in  the  position  in  which 
it  has  been  placed  by  the  accident.  Any  attempt  to  correct  the 
deformity  is  luijustifiable  and  would  necessarily  result  in  loosening  of 


462 


SPECIAL    FRACTURES. 


the  impaction,  an  event  that  would  be  followed,  almost  to  a  certainty,  by 
nonunion,  tmless  it  were  again  reproduced  artificially  and  maintained 
by  fixation.     Extension  is  useless  in  these  cases. 

Permanent  fixation  of  an  impacted  fracture  is  necessary  for  the 
following  reasons  :  ^ 

1.  It  maintains  the  impaction. 

2.  It  prevents  secondary  shortening  and  eversion  during  the 
osteoporotic  stage  of  the  reparative  process. 

3.  By  keeping  the  injured  parts  at  rest  it  serves  as  a  preventive 
measure  against  the  accession  of  arthritis  and  para-arthritis. 

It  enables  the  patient  to  leave  the  bed  before  complete  consoli- 
dation of  the  fracture  has  taken  place.      Extension  is  always  con- 

b  traindicated  in  these  cases, 

as  it  certainly  can  do  no 
good  and  may  result  in  ir- 
reparable damage  by  loos- 
ening the  impaction.  The 
best  dressing  to  accom- 
plish permanent  fixation  is 
a  plaster-of-Paris  bandage. 
To  insure  complete  immo- 
bility of  the  hip-joint  the 
bandage  must  include  the 
injured  limb  from  the  toes 
upward,  the  entire  pelvis, 
and  the  sound  limb  from 
the  pelvis  to  at  least  as  far 
as  the  knee.  For  the  pur- 
pose of  greater  durability 
and  security  of  the  dress- 
ing a  tin  or  wood  splint 
can  be  incorporated  in  the 
plaster  bandage.  In  the 
application  of  this  bandage 
it  is  necessary  to  protect 
all  prominent  bony  pro- 
jections, more  especially  the  trochanter  major  over  the  affected 
side,  with  salicylated  cotton,  to  guard  against  excoriations  ;  a  thin 
layer  of  absorbent  cotton  should  be  applied  next  the  skin  and  held 
in  place  by  a  gauze  bandage.  During  the  application  of  the  ban- 
dages, and  until  the  plaster  sets,  it  is  necessary  to  place  the  patient 
on  a  pelvic  rest,  such  as  is  described  by  Bardeleben.  During  the 
setting  of  the  plaster  it  is  important  to  make  lateral  pressure  over 
both  the  greater  trochanters,  in  order  to  secure  firm  support  to  the 
broken  bone. 

With  such  a  dressing  the  patient  can  be  moved  without  fear  of 
disturbing  the  fracture,  and  in  a  few  days  he  can  leave  the  bed,  and 
in  a  few  weeks  can  walk  on  crutches,  if  this  is  deemed  necessary 


Fig.  287.— Pelvic  supports,  to  be  used  in  ap- 
plying plaster-of-Paris  dressing  in  fractures  of  the 
thigh  and  neck  of  femur :  a,  Von  Esmarch'  s  ;  b, 
von  Bardeleben' s. 


TREATMENT. 


463 


for  the  purpose  of  preventing  complications.  Unless  indications 
arise,  it  is  advisable  not  to  disturb  the  dressing  until  osseous  union 
has  become  sufficiently  firm  to  support  the  fragments.  It  is  par- 
ticularly dangerous  to  change  the  dressing  in  from  the  third  to  the 


Fig.  28S. — Von  Volkmann's  pelvic  support,  to  be  used  in  applying  plaster-of- Paris  dress- 
ing in  fractures  of  the  thigh  and  neck  of  femur  (von  Esmarch). 


fifth  week,  as  during  this  time  the  inflammatory  osteoporosis  has  a 
tendency  to  loosen  the  fragments.  A  dressing  of  this  kind  is  vastly 
superior  to  any  splint  in  affording  comfort  to  the  patient  and  in 
securing  the  best  attainable  result.      In   very  feeble   and  decrepit 

patients,  where  such  per- 
manent fixation  is  not  ap- 
plicable, the  best  plan  to 
pursue  is  to  place  the  pa- 
tient in  a  bed  properly  pre- 
pared, and  in  a  position 
that  will  prove  most  com- 
fortable to  the  patient,  most 
conducive  to  securing  mus- 
cular relaxation,  and  most 
favorable  toward  the  pre- 
vention of  decubitus.  With 
the  head  and  chest  slightly 
elevated,  a  double  inclined 
plane,  sand-bags  on  the 
sides  of  the  limb,  a  pelvic 
belt  with  a  compress  over 
the  trochanter  major  of  the 
injured  side,  will  contribute 
much  toward  keeping  the 
fractured  surfaces  in  contact.  Strict  attention  to  cleanliness  and 
proper  attention  ta  the  skin  will  do  much  toward  preventing 
decubitus. 

In  the  treatment  of  nonimpactcd  fractures  the  same  principles 


Fig.  289. — Senn's 
apparatus  for  making 
lateral  pressure  in  the 
treatment  of  fractures  of 
the  neck  of  the  femur. 


Fig.     290.  —  Senn's 
apparatus  applied. 


464  SPECIAL    FRACTURES. 

should  govern  us  as  in  the  impacted  variety.  In  this  class  of  frac- 
tures, however,  another  important  indication  arises — namely,  to  effect 
coaptation  of  the  fractured  ends  ;  at  the  same  time  retention  is  more 
difficult  to  accomplish.  The  closer  we  can  imitate  impaction,  the 
better  are  the  prospects  for  a  favorable  result.  If  we  could  keep 
the  broken  surfaces  in  perfect  coaptation  and  maintain  retention  and 
immobility,  these  fractures  would  heal  in  the  same  way  as  impacted 
fractures.  '  That  these  indications  have  not  been  fulfilled  by  the 
usual  treatment  with  different  splints,  extension  by  weight  and  pul- 
ley, and  pelvic  belt,  nobody  can  deny.  Even  extracapsular  frac- 
tures have  healed,  as  a  rule,  with  so  much  shortening  as  to  cripple 
the  patients  for  life,  while  the  results  after  intracapsular  fractures 
have  almost  uniformly  been  bad  ;  for  this  reason  many  distin- 
guished surgeons  have  abandoned  all  active  measures,  limiting  their 
attention  exclusively  to  palliation. 

Prominent  among  the  advocates  of  the  expectant  treatment  in 
intracapsular  fractures  may  be  mentioned  Sir  Astley  Cooper,  Vel- 
peau,  Langlet,  and  Lavacherie.  That  the  views  of  many  surgeons 
on  this  point  have  undergone  no  material  change  since  Sir  Astley 
Cooper's  time  is  apparent  from  more  than  one  recent  work  on  sur- 
gery. In  Gant's  "  Surgery,"  on  page  647,  we  read  as  follows  : 
"  No  bony  union  taking  place,  as  a  rule,  in  intracapsular  fractures 
of  the  neck  of  the  femur,  it  will  generally  be  useless  to  adjust  the 
fracture  and  apply  any  retentive  apparatus  with  a  view  to  such 
union  ;  and  the  more  so  in  proportion  to  the  years  of  the  patient." 

The  older  methods  of  treatment  are  well  illustrated  by  the  views 
of  Dr.  E.  M.  Moore,  the  veteran  surgeon  of  Rochester,  N.  Y.,  who, 
after  a  long  and  rich  experience,  writes  as  follows  : 

"  In  case  of  extracapsular  fracture  we  expect  union  by  bone.  A 
favorable  result,  with  shortening  from  one  to  three  inches,  can  be 
pretty  well  assured  by  simple  expectation.  When  the  intra-articular 
form  occurs,  a  proper  therapeusis  is  important.  If  the  so-called 
cervical  ligament  remains  unbroken,  it  becomes  thickened  and 
reinforced,  and  after  about  two  months  becomes  strong  enough  to 
bear  the  weight  of  the  patient.  The  limb  being  shortened  about 
an  inch,  with  foot  slightly  everted,  no  union  by  bone  is  to  be  ex- 
pected. The  possibility  of  such  union  has  been  strenuously  denied. 
A  few — a  very  few — cases  have  been  brought  forward  to  prove 
union  by  bone. 

"  From  what  has  been  stated  above,  it  can  be  seen  that  in  the 
condition  ordinarily  resulting  from  this  accident — viz.,  where  there 
has  been  a  shortening  of  the  neck  by  crushing  of  bone  tissue — 
union  would  be  impossible.  But  in  a  case  of  extreme  rarity,  where 
a  sudden  twist  would  snap  off  the  neck  without  any  crushing  of 
tissue,  it  is  hardly  to  be  supposed  that  a  bony  union  might  not 
occur.  Professor  Senn's  experiments  on  cats  demonstrated  this 
perfectly.  But  in  making  a  fracture  for  experiment,  just  the  con- 
dition described  would  occur.     The  tissue  would  not  be  crushed. 


TREATMENT,  465 

and  the  broken  surfaces  would  touch.  It  becomes  highly  important 
to  protect  this  hgamentous  tissue,  while  nature  is  thickening  and 
strengthening  the  band  that  will  extend  from  the  head  to  the  neck. 
It  has  been  proposed  to  confine  the  patient  with  a  long  splint  to 
attain  this  object.  But  old  age  does  not  tolerate  such  confinement 
readil}',  and  a  fatal  result  might  disappoint  the  surgeon.  Still,  it  is 
wise  to  guard  against  the  danger  incident  to  the  steady  strain  of 
the  muscles  of  the  thigh.  The  necessary  restraint  can  be  obtained 
by  appending  a  weight  to  the  limb.  This  can  be  most  easily 
obtained  by  the  application  of  adhesive  plaster.  The  amount  of 
weight  may  vary  from  five  to  fifteen  or  twenty  pounds.  It  should 
be  regulated  by  the  sensation  of  the  patient :  that  which  produces 
the  greatest  comfort  is  to  be  adopted.  All  other  restraint  should 
be  avoided,  but  even  this  must  sometimes  be  given  up,  and  the 
patient  should  sit  up  and  even  use  crutches  to  maintain  health. 
Nevertheless,  the  sensation  of  the  greatest  comfort  to  the  patient  is 
the  best  measure  of  what  is  necessary  to  antagonize  the  contraction 
of  the  thigh  muscles. 

"  The  same  method  is  suitable  for  both  forms  of  fracture.  The 
strips,  three  or  four  inches  in  width,  and  long  enough  to  reach  from 
the  groin  to  four  inches  below  the  foot,  held  in  contact  with  the 
skin  by  a  roller  bandage  the  whole  distance,  and  held  apart  at  the 
lower  end  by  a  wooden  brace  so  as  to  protect  the  ankles  from 
pressure,  is  a  simple  and  efficient  device.  To  this  brace  a  cord 
may  be  attached,  which,  carried  over  a  pulley,  holds  the  weight 
necessary."  fi^ 

This  is  the  treatment  that  has  been  employed  for  years  and  that 
may  be  resorted  to  with  advantage  in  cases  in  which  more  radical 
measures  are  contraindicated.  The  treatment  detailed  by  the  dis- 
tinguished surgeon  who  has  done  so  much  in  perfecting  the  treat- 
ment of  a  number  of  fractures  has  never  succeeded  in  securing  bony 
union  in  cases  of  nonimpacted  intracapsular  fractures,  its  sole  bene- 
fit consisting  in  placing  the  capsular  ligament  in  a  favorable  condi- 
tion to  become  strengthened,  and  later  serve  as  a  substitute  for  the 
fractured  neck  in  supporting  the  weight  of  the  body.  There  are 
cases  in  which  this  conservative  course  is  the  only  alternative — when, 
from  the  general  condition  of  the  patient  or  the  presence  of  serious 
complicati(jns,  perfect  reduction  and  permanent  immobilization  are 
contraindicated.  For  such  cases  I  recommend  extension  by  weight 
and  pulley,  lateral  support  of  limb  by  sand-bags,  and  pressure 
against  the  greater  trochanter  by  compress  and  pelvic  belt. 

If  the  results  attending  the  different  methods  of  treatment  have 
been  so  bad  as  to  induce  men  of  the  highest  professional  attain- 
ment to  abandon  all  active  treatment,  the  question  naturally  arises. 
Are  there  any  other  means  that  are  better  adapted  to  accomplish 
the  desired  result  ?  The  inquiry  as  to  the  possible  bony  union 
after  intracapsuhir  fracture,  in  the  light  of  recent  rescaiches  has 
been  decided  in  the  affirmative,  and  a  more  practical  query  arises, 
30 


466  SPECIAL    FRACTURES. 

How  can  it  be  obtained  ?  By  what  means  can  we  keep  the  frag- 
ments in  mutual  coaptation  during  the  process  of  repair  ?  The 
following  points  suggest  themselves  in  the  treatment  undertaken 
for  the  purpose  of  obtaining  bony  union  in  nonimpacted  fractures 
of  the  neck  of  the  femur  : 

1.  Immediate  reduction  and  coaptation  of  the  fracture  :  if  need 
be,  under  the  influence  of  a  general  anesthetic. 

2.  Fixation  with  a  plaster-of-Paris  splint. 

3.  Lateral  pressure. 

4.  Direct  fixation  of  fragments  by  aseptic  ivory  or  bone  nail. 

Extension  by  means  of  weight  and  pulley  overcomes  the  short- 
ening, only  gradually,  and  seldom  completely  ;  at  the  same  time 
it  necessitates  the  recumbent  position  for  a  long  time,  and  thus 
exposes  the  patient  to  all  the  risks  and  inconveniences  incident  to 
such  position.  If  the  patient  is  placed  thoroughly  under  the  influ- 
ence of  an  anesthetic,  muscular  action  is  temporarily  annihilated,  and 
the  limb  can  be  extended  at  once  to  its  natural  length,  while  coap- 
tation can  be  effected  at  the  same  time.  If  reduction  is  made  with 
the  patient  under  the  influence  of  an  anesthetic,  some  kind  of  a  pel- 
vic rest  is  necessary  in  the  subsequent  application  of  the  fixation 
dressing.  The  advantages  arising  from  immediate  reduction  and 
coaptation  are  the  following  : 

1.  The  untorn  portions  of  the  joint  structures  are  replaced  at 
once  in  their  normal  relations,  a  procedure  that  can  not  fail  to 
influence  favorably  the  circulation  in  vessels  that  may  have  escaped 
injury. 

2.  The  sharp  and  irregular  margins  of  the  broken  surfaces  act 
as  irritants  to  the  surrounding  soft  tissues  ;  immediate  reduction,  by 
placing  the  bones  at  once  in  mutual  coaptation,  acts  as  a  preventive 
against  the  supervention  of  undue  irritation  and  inflammation  in  and 
around  the  hip-joint. 

3.  With  coaptation  the  process  of  repair  is  initiated  at  once,  and 
the  blood  and  exudation  material  between  the  frag-ments  act  as  a 
temporary  cement  substance,  at  the  same  time  serving  a  useful  pur- 
pose in  reestablishing  the  interrupted  circulation. 

4.  Perfect  reduction  and  coaptation  prevent  muscular  spasms 
and  diminish  pain. 

Having  reduced  the  fracture,  retention  should  be  maintained 
in  a  similar  manner  as  in  impacted  fractures,  with  the  exception, 
however,  that  eversion  should  be  carefully  corrected.  The  plaster- 
of-Paris  splint  is  applied  as  for  impacted  fracture,  only  that  over  the 
trochanter  major  of  the  injured  side  a  fenestra,  about  two  inches 
wide  and  four  inches  long,  is  left  open  for  the  purpose  of  applying 
lateral  pressure. 

Many  fractures  of  the  femoral  neck  are  kept  from  becoming 
displaced  for  a  variable  period  of  time  by  interlocking  of  the  den- 
ticulated broken  surfaces,  a  condition  that  has  been  called  by  Bigelow 
"  rabbeting."     Believing  that  the  surgeon  should  imitate  the  repara- 


TREATMENT.  467 

tive  resources  of  nature  whenever  it  is  possible  to  do  so,  it  appears 
to  me  that  artificial  rabbeting  could  often  be  produced  by  lateral 
pressure.  The  fractured  surfaces  being  placed  as  accurately  as 
possible  opposite  each  other,  lateral  pressure  would  cause  coapta- 
tion and  a  mutual  interlocking  of  the  fragments.  Lateral  pressure 
applied  with  this  view  would  be  one  of  the  most  reliable  means  of 
preventing  secondary  lateral  and  longitudinal  displacements.  Pres- 
sure, to  be  effective,  must  be  applied  in  the  direction  of  the  broken 
neck, — that  is,  over  the  trochanter  major, — and  in  such  a  manner 
as  not  to  interfere  with  the  superficial  circulation.  Pressure  with 
belts  and  strips  of  adhesive  plaster  encircling  the  whole  pelvis  can 
exert  but  little  influence  on  the  fractured  bone  ;  at  the  same  time  it 
impedes  the  superficial  circulation.  With  the  fenestrated  plaster-of- 
Paris  splint  pressure  can  be  applied  directly  over  the  trochanter 
major  by  placing  a  well-cushioned  pad,  with  a  stiff,  unyielding  back, 
corresponding  in  size  to  the  fenestra,  in  the  opening  of  the  splint, 
and  applying  the  necessary  amount  of  pressure  by  means  of  a  Petit 
tourniquet  or  some  other  similar  contrivance.  A  small  amount  of 
pressure,  if  well  directed,  would  be  sufficient  to  retain  the  fragments 
in  apposition.  .  By  removing  the  pad  from  time  to  time  and  wash- 
ing the  parts  with  dilute  alcohol  there  would  be  no  danger  of  pro- 
ducing excoriation.  The  pad  could  also  be  made  smaller,  and  the 
pressure  surface  changed  as  often  as  necessary  as  an  additional 
precaution  against  decubitus. 

Apposition  of  the  fractured  ends  could  be  secured  and  main- 
tained with  the  greatest  degree  of  accuracy  by  measures  that  are 
calculated  to  operate  directly  upon  the  fragments.  Such  direct 
treatment  has  been  successful  in  other  joint  fractures  where  the  usual 
prescribed  methods  of  treatment  had  failed  in  effecting  union  by 
bone.  In  fractures  of  the  femoral  neck,  however,  the  injured  parts 
are  so  inaccessible  as  to  exclude  the  propriety  of  any  cutting 
operation  for  the  purpose  of  exposing  the  fragments  to  view  and 
securing  apposition  by  direct  fixation.  At  the  same  time,  this 
injury  usually  occurs  in  a  class  of  patients  whose  general  condition 
would  forbid  an  operation  of  such  magnitude  for  such  a  purpose. 
If,  however,  an  operation  could  be  devised  that  would  be  devoid  of 
immediate  or  remote  danger  to  life  and  that  would  not  incur  any 
loss  of  blood  nor  add  to  the  suffering  of  the  patient,  and  at  the 
same  time  would  render  substantial  aid  in  maintaining  permanent 
apposition  of  the  fragments,  then  our  prospects  for  securing  better 
results  would  indeed  become  more  encouraging.  I  hope  that  the 
same  operation  I  performed  so  successfully  on  animals  will  prove 
useful  in  the  human  subject,  in  well-selected  cases — viz.,  subcu- 
taneous drilling  and  nailing  of  the  fragments  with  an  ivory  or  a 
bone  nail.  The  observations  of  Volkmann  and  Heine  have  shown 
that  driving  ivory  pegs  into  osteoporotic  bones  will  produce  an 
osteoplastic  process  and  sclerosis  of  the  bone.  The  o[)eration  of 
drilling  and  insertion  of  b(Mie  nails  has  been   resorted  to  for  a  long 


468  SPECIAL    FRACTURES. 

time  for  the  purpose  of  promoting  the  formation  of  callus  in  cases 
of  ununited  fractures,  and  it  is  only  reasonable  to  assume  that  the 
same  treatment  would  have  a  similar  effect  in  recent  fractures.  The 
operation  offers  no  technical  difficulties,  and  if  done  under  strict 
aseptic  precautions,  does  not  expose  the  patient  to  any  additional 

risks. 

The  idea  of  immobilizing  fractures  by  nailing  the  ends  of  the 
broken  bone  together  is  not  a  new  one.  It  is  alluded  to  by  David 
Prince  in  treating  of  the  subject  of  ununited  fractures,  when  he 
says:  "Perhaps  a  bone  might  be  drilled  through  both  fragments 
and'  held  in  apposition  by  a  rivet  of  one  of  these  metals.  The  pres- 
ence of  the  rivet  after  the  completion  of  the  healing  process  would 
do  no  harm,  and  if  a  permanent  discharge  should  be  the  result,  the 
metal  could  be  readily  removed." 

As  yet  a  discrepancy  of  opinion  prevails  as  to  the  future  fate  of 
bone  and  ivory  pegs  when  embedded  in  living  bone.  Trendelen- 
burg operated  for  a  very  oblique  ununited  fracture  of  the  femur  at 
the  junction  of  the  lower  with  the  middle  third  by  fixing  the  frag- 
ments with  an  ivory  peg.  He  had  an  opportunity  to  examine  the 
specimen  two  and  one-half  years  after  the  operation.  The  fracture 
was  firmly  united,  and  the  ivory  peg  was  found  intact  in  the  bone 
tissue,  having  undergone  no  change  whatever,  except  that  a  por- 
tion that  had  projected  into  the  knee-joint  had  become  detached 
and  was  found  embedded  in  a  cyst  in  the  interior  of  the  joint,  sur- 
rounded by  giant  cells. 

Riedinger  made  similar  observations.  Introducing  ivory  or 
bone  pegs  into  the  bones  of  animals,  he  found  them  after  a  variable 
period  of  time  either  entirely  unchanged  or  only  slightly  diminished 
in  size.  The  diminution  in  size  appeared  to  be  in  proportion  to  the 
vascularity  of  the  living  bone.  The  growth  of  the  bones  thus 
treated  was  stimulated,  as  was  shown  from  an  increase  in  their 
length  as  compared  with  the  opposite  bones. 

Bidder  found  that  by  boring  a  hole  into  the  spongiosa  of  the  epi- 
physis of  the  long  bones  in  old  rabbits — into  the  lower  end  of  the 
femur,  for  example — no  regeneration  of  bone  took  place,  the  loss 
of  substance  being  replaced  by  fibrous  and  myeloid  tissue.  In 
young  adult  rabbits  a  slight  attempt  at  regeneration  was  manifested. 
The  process  of  regeneration,  however,  was  increased  by  driving 
ivory  pegs  into  the  perforations  or  by  injecting  iodin  or  lactic  acid. 
Brainard  taught  that  simple  perforations  of  bone  increased  the 
formation  of  callus,  while  insertion  of  ivory,  wooden,  or  metallic 
nails  not  only  diminished  it,  but  with  few  exceptions  produced 
absorption  of  bone. 

Volkmann  treated  a  false  joint  of  the  femur  by  excision  of  the 
fractured  ends,  and  immobilized  the  new  fracture  by  driving  a  nail 
made  of  a  piece  of  fresh  bone  taken  from  another  patient  into  the 
medullary  cavity  of  both  pieces.  The  fracture  united,  and  the 
transplanted  piece  was  not  seen  again. 


TREATMENT. 


469 


Riedincrer's  experiments  on  animals  have  shown  that  ivory  and 
bone  nails  Implanted  into  bone  increase  the  nutrition  of  the  bone, 
and   remain   without   giving   rise  to  any  undue  u-ntation,  and  are 
finally  partially  or  completely  absorbed.      Metallic  substances  re- 
main' firmh'  embedded  in  bone  ;  wood  and  rubber  mvanably  giv^ 
rise  to  suppurative  inflammation.      Clinical  experience  and  experi- 
mental investigations  have  sufficiently  demonstrated  that  bone  and 
ivory  nails,  if  implanted  under  aseptic  precautions,  do  not  act  as 
foreicrn  bodies,    and   never   give   rise   to   suppuration.     They   can 
therel-ore   be   safely  employed  in   securing   accurate  coaptation  of 
recent  fractures,  if  this  is  deemed  advisable  and  necessary,  and  is 
not  obtainable  by  simpler  measures.      It  has  also  been  shown  that 
these  nails  stimulate  the  bone  tissue  and  thus  materially  hasten  the 
process  of  repair,  and  are  ultimately  removed  by  absorption.      1  he 
operation  of  direct  immobilization   of  the  fragments  by  means  of 
bone  or  ivory  nails  is,  therefore,  particularly  adapted  to  the  treat- 
ment of  intracapsular  fractures  whenever  it  is  decided  to  make  every 
legitimate  attempt  to  secure  union  by  bone.     A  somewhat  similar 
op^'eration  has  been  performed  repeatedly  for  the  purpose  of  reliev- 
incr  the  pain  and  functional  disability  in  old  cases  of  fracture  of  the 
ne^'ck  of  the  femur  followed  by  the  formation  of  a  false  joint. 

Before   the   introduction    of  aseptic   surgery  von    Langenbeck 
operated  by  exposing  the  greater  trochanter,  and  passing  a  silvered 
drill  through  it  into  the  upper  fragment,  so  as  to  secure  apposition. 
The  fracture  was  oblique  and  extracapsular,  in  an  aged  female      1  he 
operation  was  followed  bj-  destructive  inflammation,  hospital  gan- 
grene, and  death.      Lister  operated  in  a  similar  manner,  but  under 
the  protection  of  antiseptic  surgery,  and  secured  a  good  result  by  a 
short  fibrous   union.      In   this   case,  however,  it   appears   that   the 
upper  fragment  was  not  transfixed  by  the  screw.      Koenig  repeated 
Langenbeck's  operation    under  aseptic  precautions  and  secured  a 
favorable  result.     The  experiments  made  by  the  author  on  animals 
have   satisfied  him   that  it  is  not  always  an  easy  task  to  find  the 
upper  fragment  with  the  drill  and  perforate  it  at  the  proper  point. 
To  overcome  this  difficulty  it  has  been  suggested  by  Trendelenburg 
to  expose  the  seat  of  fracture  by  a  small  incision  from  behind,  and, 
after  forcibly  abducting  the  limb,  perforate  the  lower  fragment  from 
within  outward,  and  by  reinserting  the  drill  from  without  inward, 
guided  by  a  finger  in  the  wound,  after  straightening  the  limb    to 
transfix  the  upper  fragment.     A  silver  screw  is  inserted  in  the  hole 
made  by  the  drill,  and   the  two  fragments  are  screwed  togetliei. 
The  screw  is  to  be  removed  after  two  weeks.     For  the  purpo.ses  lor 
which  we  have  urged  the  operation  Trendelenburg's  method  is  too 
severe  and  dangerous.      By  using  bone  or  ivory  pegs  no  disastrous 
result  would  follow  in  ca.se  the  peg  should  miss  the  upper  fragment 
and  be  driven  into  the  joint. 

Trendelenburg's  case  and  my  experiments  on  animals  furnish 
positive  proof  that  bone  and  ivory  pegs  driven  into  the  interior  ot 


470 


SPECIAL    FRACTURES. 


joints  do  not  give  rise  to  any  serious  results.  The  operation  of 
drilling  the  femoral  neck  and  the  subsequent  insertion  of  the  ivory 
peg  is  facilitated  by  placing  the  limb  in  its  natural  position  and 
securing  it  by  a  plaster-of-Paris  dressing.  The  drilling  is  done 
through  the  fenestra  over  the  greater  trochanter  in  the  plaster 
spHnt,  by  sliding  the  skin  and  making  a  passage  for  the  drill  with  a 
tenotome  through  the  soft  tissues  down  to  the  bone,  at  a  point  cor- 
responding to  the  center  of  the  base  of  the  femoral  neck,  and  drill- 
ing in  the  direction  of  its  axis  toward  and  into  the  femoral  head. 
The  length  of  the  bone  or  ivory  peg  should  correspond  to  the  dis- 
tance between  the  outer  surface  of  the  greater  trochanter  and  the 
center  of  the  femoral  head.  The  advantages  arising  from  the  treat- 
ment suggested  would  be  : 

1.  A  perfect  degree  of  coaptation  and  immobilization  of  the 
fragments. 

2.  The  patient  could  be  placed  in  any  position  in  bed,  or  even 
be  taken  outdoors  as  soon  as  the  dressing  is  applied,  thus  effectually 
preventing  excoriations  and  the  diseases  incident  to  prolonged  con- 
finement to  bed  in  the  recumbent  position. 

Tlie  subcutaneous  drilling  and  transfixion  of  the  fragments  zvith 
an  aseptic  bone  or  ivory  nail  must  he  restricted  to  cases  i7i  which  there 
are  no  contraindications  and  in  which  bony  union  by  such  treatment 
can  be  confidently  expected.  Such  cases  are  necessarily  fezv.  Obesity, 
great  general  debility,  atheroma  and  arteriosclerosis,  complicating  dis- 
eases, and  very  old  age  are  contraindications  that  must  not  be  ignored. 
Direct  fixation  in  recent  fractures  must  be  combined  with  immobiliza- 
tion of  the  limb  and  pelvis.  The  open  operation  for  direct  fixation 
must  be  reserved  for  the  relief  of  pain  and  functional  disability  in 
well-selected  cases  of  pseudarthrosis  folloiving  fracture  of  the  femoral 
neck.  It  is  an  operation  of  considerable  magnitude,  and  should  not 
be  undertaken  lightly. 

An  extensive  clinical  experience  has  satisfied  me  that  direct 
measures  of  fixation  are  seldom  called  for  in  the  treatment  of  recent 
unimpacted  fractures  of  the  neck  of  the  femur,  as  the  same  results 
can  be  obtained  by  well-regulated  lateral  pressure  in  the  direction  of 
the  axis  of  the  femoral  neck,  combined  with  perfect  fixation  of  the 
lower  fragment  upon  the  pelvis.  The  influence  exercised  by  impac- 
tion in  determining  the  ultimate  result  in  fractures  within  the  cap- 
sule of  the  hip-joint  has  been  repeatedly  alluded  to. 

Many  fractures  of  the  femoral  neck  are  kept  from  becoming  dis- 
placed for  a  variable  period  of  time  by  interlocking  of  the  denticu- 
lated broken  surfaces,  a  condition  that  has  been  termed  by  Bigelow 
"  rabbeting."  Believing  that  the  surgeon  should  imitate  the  repar- 
ative resources  of  nature  whenever  it  is  possible  to  do  so,  it  occurred 
to  me  that  artificial  rabbeting  could  be  produced  in  all  cases  by  un- 
interrupted lateral  pressure.  It  is  not  difficult  to  conceive  that  if  the 
fractured  surfaces  are  placed  as  accurately  as  possible  in  apposition, 
lateral  pressure  would  effect  perfect  approximation  and  a  mutual 


REDUCTION    AND    FIXATION.  47 1. 

interlocking  of  the  fragments.  Lateral  pressure  thus  applied  is  one 
of  the  most  efficient  means  in  preventing  secondary,  lateral,  and 
longitudinal  displacements.  Pressure,  to  be  effective,  must  be  ap- 
plied in  the  direction  of  the  broken  neck — that  is,  directly  over  the 
trochanter  major,  and  in  such  a  manner  as  not  to  interfere  with  the 
superficial  circulation.  Pressure  with  belts  and  strips  of  adhesive 
plaster  encircling  the  whole  pelvis  can  exert  but  little,  if  any,  influ- 
ence on  the  fractured  bone  ;  at  the  same  time  it  impedes  the  super- 
ficial circulation.  In  the  more  recent  cases  of  fracture  of  the  neck 
of  the  femur  that  have  come  under  my  observation  I  have  pursued 
the  following  plan  of  treatment : 

The  patient  is  dressed  in  well-fitting  knit  drawers  and  a  thin 
pair  of  stockings.  For  strengthening  the  plaster-of-Paris  dressing 
over  the  joints,  and  at  other  points  where  greater  strength  is 
required,  oaken  shavings  or  strips  of  tin  are  placed  between  the 
layers  of  plaster.  These  small  thin  splints  greatly  increase  the 
durability  of  the  dressing  without  adding  much  to  its  weight.  The 
bony  prominences  are  protected  with  cotton  before  the  plaster-of- 
Paris  dressing  is  applied.  The  drawers  and  stockings  furnish  a 
more  complete  and  better  protection  to  the  skin  than  roller  ban- 
dages. Usually  about  twenty-four  plaster-of-Paris  bandages  are 
required  for  a  dressing.  The  fractured  limb  is  first  incased  in  the 
dressing  as  far  as  the  middle  of  the  thigh,  after  which  the  patient 
is  lifted  out  of  bed  by  two  strong  persons,  the  physician  supporting 
the  limb  so  as  to  prevent  disengagement  of  the  fragments  if  the 
fracture  is  impacted,  and  to  guard  against  additional  injuries  in 
nonimpacted  fractures.  The  patient  is  placed  in  the  erect  position, 
standing  with  his  sound  leg  upon  a  stool  or  box  about  two  feet  in 
height ;  in  this  position  he  is  supported  by  a  person  on  each  side 
until  the  dressing  has  been  applied  and  the  plaster  has  set.  A 
third  person  takes  care  of  the  fractured  limb,  which  is  gently  sup- 
ported and  immovably  held  in  impacted  fractures  until  permanent 
fixation  has  been  secured  by  the  dressing.  In  nonimpacted  frac- 
tures the  weight  of  the  fractured  limb  makes  autoextension,  which 
is  often  quite  sufficient  to  restore  the  normal  length  of  the  limb  ; 
if  this  is  not  the  case,  the  person  who  has  charge  of  the  limb  makes 
traction  until  all  shortening  has  been  overcome,  as  far  as  pos- 
sible, at  the  same  time  holding  the  limb  in  a  position  so  that  the 
great  toe  is  on  a  straight  line  with  the  inner  margin  of  the  patella 
and  the  anterior  superior  spinous  process  of  the  ilium.  In  apply- 
ing the  plaster-of-Paris  bandages  over  the  seat  of  fracture  a  fenes- 
tra, corresponding  in  size  to  the  dimensions  of  the  compress  with 
which  the  lateral  pressure  is  to  be  made,  is  left  open  over  the  great 
trochanter. 

To  secure  perfect  immobility  at  the  scat  of  fracture  it  is  not 
only  necessary  to  include  the  fractured  limb  and  the  entire  pelvis  in 
the  dressing,  but  it  is  absolutely  necessary  to  include  the  opposite 
limb  as  far  as  the  knee,  and  to  extend  the  dressing  as  far  as  the 


472  SPECIAL    FRACTURES. 

cartilage  of  the  eighth  rib.  The  sphnt  which  is  represented  by- 
figure  289  is  incorporated  in  the  plaster-of- Paris  dressing,  and  must 
be  carefully  applied,  so  that  the  compress,  composed  of  a  well- 
cushioned  pad  with  a  stiff  unyielding  back,  rests  directly  upon  the 
trochanter  major,  and  the  pressure  that  is  made  by  a  set-screw  is 
directed  in  the  axis  of  the  femoral  neck.  The  set-screw  is  projected 
by  a  key  that  is  used  in  regulating  the  pressure.  Lateral  pressure 
is  not  applied  until  the  plaster  has  completely  set.  If  the  patient 
is  well  supported  and  the  fractured  limb  is  held  immovably  in 
proper  position,  but  little  pain  is  experienced  during  the  application 
of  the  dressing.  Syncope  should  be  guarded  against  by  the  ad- 
ministration of  stimulants.  As  soon  as  the  plaster  has  hardened 
sufficiently  to  retain  the  hmb  in  proper  position,  the  patient  should 
be  laid  upon  a  smooth,  even  mattress,  without  pillows  under  the 
head,  and  in  nonimpacted  fractures  the  foot  is  held  in  a  straight 
position  and  extension  is  kept  up  until  lateral  pressure  can  be 
applied.  The  lateral  pressure  prevents  all  possibility  of  disengage- 
ment of  the  fragments  in  impacted  fractures,  and  in  nonimpacted 
fractures  it  creates  a  condition  resembling  impaction  by  securing 
accurate  apposition  and  mutual  interlocking  of  the  uneven  fractured 
surfaces.  No  matter  how  snugly  a  plaster-of-Paris  dressing  is 
applied,  it  becomes  loose  in  a  few  days,  as  the  result  of  shrinkage, 
and  without  some  means  of  making  lateral  pressure  it  would 
become  necessary  to  change  it  from  time  to  time  in  order  to  render 
it  efficient.  But  by  incorporating  a  splint  in  the  plaster  dressing, 
as  shown  in  figure  290,  this  is  obviated,  and  the  lateral  pressure  is 
regulated  from  day  to  day  by  moving  the  set-screw,  the  proximal 
end  of  which  rests  in  an  oval  depression  in  the  center  of  the  pad. 
From  time  to  time  the  pad  is  removed  and  the  skin  washed  with 
dilute  alcohol,  for  the  purpose  of  guarding  against  decubitus. 

After=treatment. — If  the  application  of  the  dressing,  as  just 
described,  is  a  tedious,  laborious,  and  difficult  task,  it  will  richly 
compensate  both  physician  and  patient  during  the  after-treatment. 
I  have  never  found  it  necessary  to  apply  more  than  one  dress- 
ing. If  the  fracture  is  properly  reduced  and  the  limb  fixed  in 
normal  position  in  the  dressing,  then  the  only  thing  that  requires 
watchful  attention  is  the  regulation  of  the  lateral  pressure.  The 
patient  can  move  himself  in  bed  and  can  lie  on  the  back,  face, 
and  on  either  side,  and  can  be  taken  out  of  bed  and,  if  the  weather 
is  favorable,  outdoors  daily  if  desirable,  without  pain  or  risk  of 
displacement  of  the  fragments.  If  necessary,  a  patient  in  such  a 
dressing  could  be  transported  great  distances  without  any  immediate 
or  remote  risks.  The  impunity  with  which  the  patient  can  change 
his  position  and  the  benefits  to  be  derived  from  outdoor  fresh  air 
are  advantages  that  can  not  be  obtained  by  any  other  treatment, 
and  to  them  must  be  attributed  an  important  influence  in  the  pre- 
vention of  a  number  of  the  fatal  complications  that  have  so  often 
figured  as  causes  of  death  in  patients  suffering  from  fractures  of  the 


AFTER-TREATMENT. CASES.  473 

femoral  neck.  If  the  dressing  has  been  well  applied,  and  more 
especially  if  the  precaution  has  been  followed  to  protect  the  bony 
prominences  with  a  layer  of  salicylated  cotton,  there  is  little  or  no 
danger  of  the  formation  of  excoriations.  At  the  expiration  of 
froni  eighty  to  one  hundred  da\-s,  the  time  required  for  bony  union 
to  take^pla'ce,  the  dressing  is  removed,  but  the  patient  should  be 
cautioned  not  to  make  use  of  the  limb  until  the  end  of  the  fourth 
or  sixth  month,  when  union  will  be  sufficiently  firm  to  sustain  the 
weight  of  the  body.  As  soon  as  the  dressing  is  removed  passive 
motion  should  be  niade,  and  the  nutrition  and  function  of  the  limb 
should  be  promoted  by  massage  and,  if  considerable  muscular 
atrophy  is  present,  the  use  of  the  faradic  current. 

Cases   of    Fracture   of  the   Neck   of  the    Femur  Treated   by 
Immediate  Reduction  and  Permanent  Fixation. — 

Case  i. Female,  aged  sixty-eight,  in  fair  general  health,  slipped  on  the  sidewalk 

and  fell  upon  the  right  hip.  The  examination  made  a  few  hours  after  the  accident 
revealed  a  contusion  over  the  trochanter  major,  some  swelling  about  the  region  of  the  hip- 
joint  limb  everted,  and  a  shortening  of  1%  inches.  The  displacement  of  the  great  tro- 
chanter above  Roser-Nelaton's  line  corresponded  with  the  extent  of  the  shortening. 
There  was  no  impaction.  Crepitus  was  elicited  by  the  slightest  movement  of  the  limb. 
Anatomic  diagnosis  :  Fracture  of  the  neck  of  the  femur  partially  within  and  partially 
without  the  capsular  ligament.  In  this  case  reduction  was  made  by  placing  the  patient 
upon  a  pelvic  rest  and  making  extension.  The  limb  could  be  brought  down  to  within  ,'4 
of  an  inch  of  its  normal  length,  and  in  this  position,  with  the  foot  in  proper  line,  it  was 
fixed  in  the  plaster-of- Paris  dressing,  and  as  soon  as  the  plaster  had  become  firm,  lateral 
pressure  by  means  of  the  pad  and  set-screw  was  applied.  The  patient  suffered  but  little 
pain  at  any  time,  and  could  roll  herself  in  bed  from  one  side  to  the  other  with  ease.  1  he 
dressing  was  removed  after  three  months,  when  it  was  a.scertained  that  bony  union  had 
been  obtained,  with  >^  inch  of  shortening  and  the  limb  in  good  position.  Passive  motion 
and  massage  were  now  made  daily,  and  the  patient  was  allowed  to  walk  on  crutches. 
Four  months  after  the  accident  she  was  able  to  walk  with  the  aid  of  a  cane,  and  three 
months  later  she  required  no  further  mechanical  support.  At  the  end  of  a  year  recovery 
was  complete  and  she  could  walk  nearly  as  well  as  before  the  accident. 

Case  2.— Male,  aged  sixty-five  years.  Patient  was  .somewhat  anemic,  and  presented 
evidences  of  senile  marasmus.  He  had  fallen  from  a  ladder  for  a  distance  of  about  six  feet 
directly  upon  his  left  side.  There  was  no  external  contusion,  and  swelling  over  anterior 
aspect  of  hip-joint  was  slight.  A  number  of  careful  measurements  revealed  ^X  oi  an  inch 
of  shortening.  Foot  was  moderately  everted  ;  no  impaction.  Gentle  traction  upon  the 
limb  and  slight  rotation  produced  crepitus.  After  fractured  limb  was  incased  in  plaster 
as  far  as  the  knee,  patient  was  made  to  stand  with  the  sound  limb  upon  a  stool  and  was 
suppgrted  on  each  side  by  an  assistant,  while  a  third  person  made  traction  until  the  short- 
ening was  nearly  corrected,  and  with  the  foot  in  proper  position  the  fixation  dressing  was 
applied.  Lateral  pressure  was  api)lied  the  next  day,  and  was  kept  up  carefully  for  eighty- 
five  days,  when  the  dressing  was  removed.  A  thorough  examination  showed  that  bony 
union  had  taken  place,  and  that  the  shortening  did  not  exceed  '/^  of  an  inch.  The  patient 
used  crutches  for  .six  weeks,  later  a  cane  for  a  few  months  longer,  and  at  the  end  ol  a 
year  he  walked  well  without  any  support  and  with  only  a  slight  limp. 

In  this  case  the  symptoms  after  the  accident  pointed  to  a  fracture  of  the  neck  of  the 
femdr  involving  more  of  the  bone  within  than  without  the  capsular  ligament.  Only  a 
slight  amount  of  callus  could  be  found  behind  the  posterior  margin  of  the  great  trochanter. 

Cask  3  —Female,  fiftv-eight  years  old.  Senile  marasmus  was  well  marked.  1  atient 
stumbled  and  then  fell  on  right  side.  A  few  hours  after  accident  the  right  toot  w.is  found 
everted  and  the  limb  shortened  %  of  an  inch.  There  was  no  impaction.  Right  groin 
was  considerably  swollen,  and  trochanter  major  was  displaced  backward  and  upward. 
Probable  seat  of  fracture  was  partly  within  and  partly  without  the  capsule.  Reduction 
was  efifecterl  by  autoextension  and  traction  ui)on  the  limb.  After  the  limb  was  immo- 
bilized in  tlie  dressing  the  foot  was  in  normal  position,  with  ai)parently  little  or  no  » ""rlen- 
ing.  Fixation  and  lateral  pressure  were  continued  for  three  months.  On  removal  of  the 
dressing  the  union  was  found  firm,  with  '/^  inch  of  shortening.  Patient  used  crutches 
for  three  months.      Stiffness  in  the  hip-joint  was  overcome  only  by  regular  active  and  pas- 


474 


SPECIAL    FRACTURES. 


sive  exercise  and  massage  continued  for  a  long  time.  At  the  end  of  eight  months  the 
patient  was  able  to  take  care  of  her  household,  and  the  function  of  the  limb  was  nearly 
restored.     Measurements  made  at  this  dme  showed  that  the  shortening  had  not  increased. 

Case  4.— Male,  fifty  years  old,  prematurely  aged,  the  result  of  intemperate  habits. 
Padent  slipped  and  fell  on  the  doorsteps,  fracturing  the  left  femoral  neck.  There  was 
considerable  swelling  at  the  seat  of  fracture.  Foot  was  strongly  everted  ;  shortening  i  y(. 
inches  ;  no  impacdon.  Trochanter  major  was  less  prominent  than  on  the  opposite  side, 
and  displaced  upward  above  Roser-Nelaton's  line  1%  inches.  There  was  no  impaction. 
On  making  extension  and  gently  rotating  the  limb  crepitus  could  be  distinctly  felt.  Re- 
duction and  immobilization  were  performed  in  the  usual  manner.  The  second  day  the 
patient  had  an  attack  of  delirium  tremens.  During  the  maniacal  excitement  he  tossed 
about  in  every  direction,  and  the  nurses  were  kept  busy  preventing  him  from  demolish- 
ing the  dressing.  It  was  during  this  attack  that  the  fixation  dressing  and  the  lateral 
pressure  gave  evidence  of  their  efficiency  in  maintaining  uninterrupted  coaptation  under 
the  most  unfavorable  circumstances.  Under  the  use  of  narcotics  the  patient  became 
rational  and  quiet  on  the  third  day.  The  dressing  had  to  be  repaired  in  several  places. 
Subsequentiy  the  progress  of  the  case  was  favorable.  The  dressing  was  removed  after 
ninety  days,  when  the  fracture  was  found  firmly  united,  with  nearly  an  inch  of  shortening. 
There  was  considerable  callus  in  front  of  and  behind  the  trochanter.  The  patient  was 
soon  able  to  walk  about  on  cratches,  but  no  reliable  information  could  be  obtained  as  to 
his  condition  since. 

Case  5. — A  female,  weighing  nearly  200  pounds,  was  thrown  out  of  a  buggy  and 
fell  upon  her  left  side.  After  she  recovered  from  the  immediate  effects  of  shock  she  found 
that  she  could  not  use  her  left  leg.  Two  physicians  who  examined  the  patient  soon  after 
the  injury  suspected  a  dislocation  of  the  hip,  but  made  no  attempts  at  reduction.  On 
examination  the  following  day  it  was  found  that  the  foot  was  markedly  everted,  and  a 
number  of  measurements  made  showed  j^  inch  of  shortening.  The  great  trochanter  had 
been  displaced  beyond  Roser-Nelaton'  s  line  to  the  same  extent,  and  appeared  to  be  less 
prominent  than  on  the  opposite  side.  There  was  no  swelling  in  the  groin  or  posterior 
aspect  of  the  hip-joint.  On  gently  rotating  the  limb  the  great  trochanter  described  a 
smaller  circle  than  on  the  opposite  side,  and  the  movements  affected  the  head  of  the  femur. 
Slight  traction  had  no  effect  in  diminishing  the  shortening.  The  diagnosis  of  intracap- 
sular impacted  fracture  was  based  upon  this  symptom,  and  every  precaution  was  exercised 
not  to  cause  disjunction  of  the  fragments  during  the  examination  and  the  application  of 
the  dressing.  As  it  was  important  to  maintain  the  impaction  during  the  time  required  for 
bony  union  to  take  place,  the  patient  was  treated  in  the  same  manner  as  in  the  preceding 
cases,  only  that  no  attempts  were  made  to  overcome  the  shortening  or  to  correct  the  other 
displacements.  Lateral  pressure  was  applied  in  a  line  with  the  axis  of  the  outer  portion 
of  the  femoral  neck,  for  the  purpose  of  maintaining  the  impaction  during  the  stage  of 
inflammatory  osteoporosis.  The  dressing  was  not  disturbed  for  three  months,  when  it 
was  removed,  and  the  limb  was  found  in  the  same  position  as  when  it  was  applied.  The 
shortening  had  not  increased.  The  patient  was  cautioned  not  to  use  the  limb  for  another 
three  months,  and  in  walking  to  depend  entirely  on  crutches.  For  a  long  time  the  move- 
ments in  the  hip-joint  were  impaired  undoubtedly  the  result  of  a  traumatic  plastic  inflam- 
mation of  the  structures  of  the  joint.  Passive  motion  and  massage  succeeded  in  restoring 
the  normal  function  of  the  joint.  At  no  time  could  any  callus  be  felt,  which  must  be 
considered  as  another  proof  that  the  fracture  was  intracapsular.  At  the  end  of  a  year  the 
patient  walked  nearly  as  well  as  before  the  accident. 

Case  6. — A  man,  sixty-five  years  of  age,  slipped  on  an  icy  sidewalk  and  fell  in  such 
a  manner  that  the  right  femoral  neck  was  fractured.  A  few  hours  after  the  accident  a 
considerable  swelling  had  formed  in  the  groin.  There  was  contusion  over  the  great  tro- 
chanter, and  eversion  was  so  marked  that  the  outer  margin  of  the  foot  rested  on  the  matt- 
ress. A  shortening  oi  1%  inches  was  revealed  ;  no  impaction.  Crepitus  elicited  on 
slightest  motion  of  limb.  Diagnosis  of  nonimpacted  extracapsular  fracture  of  the  neck  of 
the  femur  was  made.  Reduction  was  accomplished  by  autoextension  and  traction  on  the 
limb.  Fixation  by  means  of  plaster-of- Paris  dressing  and  lateral  pressure  were  made. 
Patient  was  relieved  of  pain  as  soon  as  the  dressing  had  been  applied,  and  remained  in 
good  health  during  the  entire  treatment,  which  was  continued  for  seventy-five  days,  when 
the  dressing  was  removed.  Bony  union  with  3^  of  an  inch  of  shortening  followed.  A 
large  mass  of  callus  on  each  side  of  the  great  trochanter  could  be  distinctly'felt.  Crutches 
were  used  for  four  months.  At  the  end  of  a  year  he  walked  without  any  support  and 
with  only  a  slight  limp. 

Case  7. — A  strong,  healthy  blacksmith  was  thrown  from  a  buggy  that  was  upset  by 
an  unruly  horse.  He  fell  in  such  a  manner  that  his  full  weight  came  upon  the  right  hip. 
Immediately  after  the  fall  he  found  that  he  was  unable  to  use  the  right  leg.  He  was 
conveyed  in  a  carriage  to  his  home,  some  three  miles  distant,  and  examination  two  hours 


COLLES'    FRACTURE.  475 

later  revealed  the  following:  Superficial  abrasion  of  skin  over  the  great  trochanter; 
marked  eversion  of  foot;  shortening  iji  inches;  tip  of  trochanter  some  distance  above 
Roser-Nelaton's  line  ;  right  femur  17 '4;,  and  left  femur  17  y^,  inches  in  length  ;  crepitus 
on  extension  and  rotation  of  the  limb  inward.  New  point  of  motion  at  seat  of  fracture 
■was  very  evident.  Pain  was  referred  to  point  immediately  behind  the  great  trochanter. 
There  was  considerable  swelling  in  the  groin  and  behind  the  great  trochanter.  The  in- 
jury was  diagnosticated  as  an  extracapsular  nonimpacted  fracture.  Reduction  by  auto- 
extension  was  made  on  the  third  day,  and  the  fracture  immobilized  by  plaster-of- Paris 
dressing,  in  which  the  splint  was  incorporated  for  making  lateral  pressure.  Patient 
suffered  but  little  pain  after  the  dressing  was  applied.  The  dressing  was  not  removed 
for  twelve  weeks,  when  a  large  mass  of  callus  was  found  behind  and  in  front  of  the  great 
trochanter,  which  for  quite  a  long  time  seemed  to  impair  the  movements  of  the  joint. 
With  the  disappearance  of  the  callus  the  functional  result  improved.  The  fracture  healed 
by  bony  consolidation,  witli  an  inch  of  shortening.  In  six  months  he  dispensed  entirely 
with  the  use  of  crutches,  and  with  a  high  sole  on  the  right  boot,  to  make  up  for  the  short- 
ening of  the  limb,  he  walked  with  only  a  very  slight  limp.  In  twelve  months  he  was  able 
to  attend  to  his  business,  even  to  horseshoeing,  and  has  since,  aside  from  the  slight  lame- 
ness, suftered  no  inconvenience  from  the  accident. 

Case  8.  —An  invalid  lady,  sixty-one  years  old,  while  descending  three  low  steps 
caught  the  left  heel  in  the  skirt  of  her  dress  and  fell,  striking  on  the  left  hip.  Examina- 
tion soon  after  revealed  the  following  s/atus  prcesens :  Dark-blue  discoloration  of  skin 
over  the  outer  and  posterior  aspect  of  the  great  trochanter,  and  from  two  to  three  inches 
below  the  hip-joint  indicated  the  point  where  the  fracturing  force  was  applied  ;  slight 
eversion  of  foot ;  no  swelling  in  groin  or  posterior  aspect  of  hip-joint ;  tip  of  great  tro- 
chanter y^,  inch  above  Roser-Nelaton's  line.  On  making  measurements  from  anterior 
superior  spine  of  the  ilium  to  the  internal  malleolus  no  shortening  could  be  detected,  but 
the  apparent  discrepancy  between  the  result  obtained  by  these  measurements  and  the 
Roser-Nelaton's  test-line  was  subsequently  explained  by  the  other  measurements,  which 
showed  asymmetry  of  the  femora,  the  femur  on  the  injured  side  being  y^,  inch  longer  than 
its  fellow  on  the  opposite  side.  Left  trochanter  rotated  on  a  shorter  radius  of  a  circle 
than  the  right.  Pain  in  the  hip  was  increased  by  pressure  over  the  great  trochanter. 
Patient  was  able  to  elevate  the  limb  about  two  feet  from  the  bed,  but  all  such  efforts 
aggravated  the  pain.  The  symptoms  in  this  case,  as  well  as  the  manner  in  which  the 
injury  occurred,  pointed  directly  to  an  impacted  intracapsular  fracture  of  the  neck  of  the 
femur.  In  order  to  secure  the  benefits  of  long-continued  impaction  during  the  process  of 
repair,  immobilization  of  the  fracture  was  secured  by  a  plaster-of- Paris  dressing  and  splint 
for  lateral  pressure.  The  general  condition  of  the  patient  was  not  impaired  by  this  kind  of 
treatment  of  the  fracture,  and  when  the  dressing  was  removed,  eight  weeks  after  its  appli- 
cation, the  limb  was  found  in  the  same  position  as  after  the  accident.  The  patient  was 
directed  to  rely  on  crutches  for  a  number  of  weeks  and  then  to  use  the  limb  cautiously. 
At  the  end  of  five  months  she  could  walk  without  a  cane  and  with  an  almost  imper- 
ceptible limp. 

I  recommend  for  adoption  the  treatment  just  described  in  all 
cases  where  there  is  a  reasonable  hope  that  by  it  a  bony  union  of 
the  fracture  will  be  obtained.  It  is  superfluous  to  remark  that  it  is 
not  applicable  in  all  cases  of  fracture  of  the  femoral  neck,  and  is 
positively  contraindicated  in  cases  of  extreme  obesity  and  debility, 
and  in  patients  suffering  from  concomitant  diseases  that,  in  them- 
selves, would  lead  to  a  fatal  termination,  in  which  event  a  purely 
palliative  treatment,  such  as  has  been  previously  detailed,  is  the  only 
one  that  the  physician  will  institute  for  the  purpose  of  securing  as 
useful  a  limb  as  is  compatible  with  an  unavoidable  pseudarthrosis 
of  the  femoral  neck. 

Colles'  Fracture. — The  importance  of  fracture  of  the  lower 
end  ii{  tlic  radius,  first  described,  from  an  anatomic  and  clinical 
.standpoint,  by  Abraham  Colles,  pertains  to  the  frequency  with 
which  it  occurs,  the  liability  of  its  being  overlooked,  and,  when 
recognized,  the  number  of  bad  results  that  follow  the  mechanical 
treatment  without  complete  reduction. 


476 


SPECIAL    FRACTURES. 


Fractures  of  the  lower  end  of  the  radius  are  the  most  frequent, 
comprising  lO  per  cent,  of  all  fractures.  Sex  and  its  consequences 
have  some  influence  as  a  predisposing  cause,  as  Morris  has  ascer- 
tained that  in  169  cases  of  these  fractures  it  occurred  114  times  in 
women  and  only  55  in  men.  The  largest  number  of  patients  were 
between  fifty  and  sixty  years  of  age.  The  senile  osteoporosity  of 
bone  during  that  period  of  life  and  the  greater  liability  to  falls  upon 
the  hand  will  explain  the  more  frequent  occurrence  of  this  fracture 
in  persons  advanced  in  years.  In  children  and  young  adults  the 
line  of  fracture  occasionally  takes  place  through  the  epiphyseal 
junction,  in  which  case  arrest  of  bone  growth  from  the  injury  to 
this  important  bone-growing  center  in  the  lower  end  of  the  radius 
constitutes  one  of  the  most  formidable  remote  consequences  of  the 


mjury. 


Professor  E.  M.  Moore,  of  Rochester,  N.  Y.,  has  made  Colles' 


Fig.  291. — Colles'  fracture,  illustrating  the  usual  seat  of  fracture  and  deformity  of  the 

wrist  (Hofta). 

fracture  of  the  radius  a  special  study  during  his  long  and  busy 
professional  career,  a  work  of  lasting  merit  for  which,  however,  he 
has  never  received  the  credit  to  which  he  is  so  well  entitled.  It 
is  my  desire  to  give  to  the  profession  the  benefits  of  Dr.  Moore's 
researches  by  inserting  here  the  most  recent  views  of  this  distin- 
guished authority  on  this  subject : 

"  Professor  Colles  drew  the  attention  of  the  profession  of  his  day 
so  earnestly  to  a  constant  misunderstanding  with  reference  to  the 
fracture  of  the  radius  at  its  lower  end  as  to  have  had  his  name  in- 
dissolubly  attached  to  it.  The  fracture  was  usually  regarded  as  a 
contusion  with  swelling,  or,  if  the  displacement  was  much,  as  a 
luxation  of  the  carpus.  These  errors  still  delude  the  profession, 
but  it  is  to  be  hoped  in  a  not  very  great  degree.  The  fracture  is  to 
be  found  from  half  an  inch  to  an  inch  and  a  half  above  the  carpal 
articulation,  usually  at  the  less  distance.     The  fragments  are  apt  to 


COLLES'    FRACTURE.  477 

be  somewhat  interlocked,  because  the  hne  of  fracture  is  in  cancel- 
lated tissue,  so  that  it  requires  a  little  force  to  separate  them  so  as 
to  get  crepitus.  If  this  is  not  done,  the  diagnosis  may  be  ot  spram, 
and  thus  becomes  a  very  great  error.  ■     ■     ,x    ,     f  ,u^ 

"  Perhaps  the  more  frequent  error  of  diagnosis  is  that  of  the 
carpal  luxation.      It  may  be  remarked  that  this  dislocation  is  ex. 
ceedincrly  rare,  and  the  fracture  perhaps  the  most  frequent  one  in 
the  body       However,  the  prominence  is  above  the  articulation  and 
with  suffident  care  crepitus  can  be  produced.     The  cause   of  this 
fracture  is  a  fall  upon  the  outstretched  palm.     Thus  the  bone  is 
broken,  and  the  cancellated  tissue  at  the  expanded  end  of  he  radius 
has  its  surfaces  somewhat  interlocked  and  the  hand  usually  a  little 
turned  to  the  radial  side  of  the  forearm.     The  hand   of  course,  fol- 
lows the   radial  fragment,  and  when  well  carried  back,  makes  a 
curve  of  the  anterior  aspect  of  the  hand  and  semi-extended  fingers 
which   has  given  to  it  the  name  of  the  '  silver-forked  fracture.       I 
think    however,  this  description  is  far  short  of  that  necessary  to 
elucidate  the  varying  conditions  direct  and  supplementary  to  this 
accident.     The  fall,  of  necessity,  has  always  a  varying  quantity  ot 
force      It  may  be  just  sufficient  to  produce  a  fracture,  as  described 
bv  Colles      But  it  may  be  a  little  more.      It  is  obvious  that  when 
the  bone  is  broken,  the  tissues  attached  to  the  ulna  must  bear  the 
strain      These  are  the  internal  lateral  ligament  and  the  triangular 
fibrocartilage.      On  examining  the  carpal  end  of  the  ulna  we  find  a 
smooth,  articulating  surface,  flanked  by  a  dull-pointed,  bony  projec- 
tion at  its  internal  border,  known  as  the  styloid  process.     From 
this  the  internal  lateral  ligament  takes  its  rise  and  is  inserted  in  the 
carpus      At  the  base  of  this  process,  and  between  it  and  the  articu- 
lating surface  at  the  end  of  the   ulna,  is   a  depression  or  pit  into 
which  the  corner  of  the  triangular  fibrocartilage  is  inserted,    \\hen 
the  radius  is  broken  at  the  point  described,  the  unexpended  force 
alluded  to  above  is  all  brought  to  bear  on  these  two  attachments 
connecting  the  hand  with  the  ulna,  directh-  through  the  ligament 
and  indirectly  through  the  fibrocartilage.     The  ulna  does  not  articu- 
late with  the  carpus,  but  finds  a  substitute  for  a  bony  socket  in  the 
fibrocartilage  which  originates  from  the  side  of  the  radius  and  covers 
the  articulating  surface  like  a  hood.      Both  the  ligament  and  carti- 
lage usually  give  way,  but  sometimes  the  cartilage  alone 

"  When  we  inspect  the  anatomic  arrangement,  it  is  palpable  that 
the  fra-ment  broken  off  from  the  radius  could  hardly  be  driven  a 
half-in?h  above  its  normal  position  without  a  rupture  of  this  singular 
liframent.  It  must  almost  inevitably  give  way  in  every  fracture  at 
this  point.  It  has  a  broad  insertion  along  the  side  of  the  end  of 
the  radius,  and  a  narrow  and  weak  one  in  the  pit  at  the  root  of  the 
styloid  process.  When  the  ligament  is  separated,  as  is  almost 
surely  done  by  pulling  off  a  scale  of  bone  or  even  the  entire  process 
wliich  is  weaker  than  the  fibrous  structure  of  the  ligament,  the 
triangular  fibrocartilage  gives  way  at  its  weakest  point,— the  inser- 


4/8  SPECIAL    FRACTURES. 

tion  into  the  pit  at  the  styloid, — and  thus  the  uhia  becomes  dislo- 
cated. But  the  force  may  be  still  more,  and  sufficient  to  change  the 
position  of  the  end  of  the  ulna.  The  scale  of  bone  drawn  from  the 
surface  of  the  styloid  process  leaves  the  end  of  the  stump,  brought 
to  a  sharp  edge  in  most  cases,  and  thus  fitted  to  penetrate  the 
tissues  with  which  it  comes  in  contact  at  the  lower  end  of  the  fore- 
arm ;  the  fascia  has  fibers  running  across  the  back  of  the  wrist,  and 
termed  the  posterior  annular  ligament.  This  unexpended  force  is 
sufficient  to  cause  the  styloid  process  to  penetrate  it  and  complicate 
the  case.  A  still  greater  force,  and  especially  if  the  resistance  is 
aided  by  fracture  of  the  radius  above  that  of  the  Colles  fracture,  or 
a  luxation  of  the  radius  at  the  elbow,  may  be  sufficient  to  push  the 
head  of  the  ulna  through  the  skin  and  produce  a  compound  dislo- 
cation. Wherever  there  is  "a  joint  there  may  be  a  luxation,  and  this 
at  a  point  described  has  been  known  both  of  the  simple  and  com- 
pound form,  but  as  a  complication  in  Colles'  fracture  has  not  been 
observed,  as  far  as  I  have  been  able  to  learn. 

"  The  comparative  frequency  of  these  various  conditions  is  dif- 
ficult of  establishment,  but  the  X-rays  have  thrown  light  upon  the 
diagnosis.  The  obscurity  that  has  long  embarrassed  surgeons  with 
reference  to  the  treatment  of  the  fracture  has  been  due  to  the 
general  ignorance  of  the  complication  arising  from  the  luxation  of 
the  ulna.  Mere  palpation  does  not  reveal  this,  and  deformity  is  the 
usual  result.  From  my  last  observation  I  had  come  to  the  conclu- 
sion that  Inxation  prevailed  in  abotit  ttvo-thirds  of  the  cases,  but  many 
skiagraphs  have  been  taken  which  render  it  probable  that  luxation 
occurs  in  nearly  all  cases,  and  that  treatment  which  provides  for  its 
reduction  and  retention  shoidd  always  be  practised,  inasmtich  as  it  is 
equally  beneficial  in  the  simpler  form.     [Italics  mine.] 

"  The  very  large  number  of  appliances  which  have  had  advocates 
and  then  were  found  to  fail  in  other  hands  testifies  to  the  inefficiency 
of  their  methods.  I  think  this  is  due  to  the  disregard  of  the  luxa- 
tion of  the  ulna.  I  will  not  undertake  a  review  of  the  methods  of 
treatment  proposed,  as  the  literature  is  encyclopedic,  as  is  apt  to 
be  the  case  where  failure  is  the  rule. 

"  The  worthlessness  of  all  splints  was  impressed  upon  me  in 
the  year  1870,  when  I  made  my  first  autopsy  of  this  fracture. 
Indeed,  they  are  a  positive  damage,  producing  an  unusual,  false  an- 
kylosis. Rectification  of  the  deforndty  is  absolutely  necessary.  This 
must  be  complete.  Anesthesia  is  called  for.  The  whole  strength  of 
the  surgeon  is  often  reqinred.      [Italics  mine.] 

"  A  direct  pull  and  a  rest  of  the  ulna  upon  the  patella  of  the 
surgeon,  with  a  strong  pull  upon  the  hand  and  forearm  of  the 
patient,^  drawing  the  hand  toward  the  ulna,  is  apt  to  rectify  the 
deformity.  But  this  must  be  as  perfect  as  can  be  made.  The  chief 
guide  is  the  position  of  the  ulna.  Before  attempting  reduction,  the 
prominence  of  the  ulna  on  the  uninjured  side  should  be  noted. 
The  prominence  of  the  head  of  the  ulna  is  remarkably  various  ;  we 


COLLES      FRACTURE. 


479 


must  bring  up  the  dislocated  head  on  a  par  with  the  sound  one. 
This  will  also  bring  the  fractured  radius  in  place.  No  splint  can 
be  more  efficient  than  a  parallel  bone  in  situ.  Where  the  fracture 
is  nearly  transverse  and  simple,  a  good  result  could  be  obtained  by 
the  mere  application  of  a  band  around  the  wrist ;  but  if  the  radius 
is  suffering  from  a  comminution,  this  can  hardly  be  sufficient.     The 


Fi".  2',2.— K.  M.  M.M.p  ■,  ,liv.. 


tr;ii  lure.      Position  of  roller  compress. 


Fig.  293. — E.  M.  Moore's  dressing  for  Colles'  fracture.      Roller  with  adhesive  strap 

applied. 

ulna  has  a  tendency  to  displacement  downward  and  forward,  and 
should  be  held  up  against  the  fascia,  which  prevents  it  from  going 
too  far.  To  accomplish  this  a  roller  of  cotton  cloth  two  inches  in 
width  and  about  three-quarters  of  an  inch  in  thickness,  very  firmly 
rolled,  should  be  placed  under  the  ulna,  extending  down  its  end, 
leaving  the  tendon  of  the  flexor  carj)i  ulnaris  on  the  radial  side. 
This  should  be  secured  by  a  strij)  of  adhesive  j)laster  not  quite  two 


48o 


SPECIAL    FRACTURES. 


inches  in  width,  which  should  be  drawn  around  the  wrist  and  roller. 
This  strip  need  not  be  warmed,  but  it  should  be  drawn  firmly,  and 
where  it  overlaps  at  the  roller,  should  be  secured  by  a  pin.  The 
warmth  of  the  wrist  soon  secures  the  full  adhesive  property  of  the 
plaster.      The  tight  strap  might  become  dangerous  if  continued,  but 


Fig.  294. — E.  M.  Moore's  dressing  for  Colics'  fracture.      Dressing  complete. 


Fig.  295. — Old-fashioned  pistol  splint  dressing  for  Colles'  fracture. 


at  the  end  of  a  few  hours  may  be  cut  through  by  inserting  the  point 
of  scissors  along  the  back  of  the  forearm.  Thus  all  strangulation  is 
absolutely  removed.  A  sling  three  inches  wide,  placed  under  the 
ulnar  roller  so  as  to  bring  the  weight  of  the  forearm  and  hand  upon 
it,  and  secured  around  the  neck,  completes  the  dressing. 


COLLES     FRACTURE. 


481 


"The  retention  of  the  hand  absolutely  quiet,  by  any  device, 
and  surely  if  splints  are  used,  is  apt  to  give  rise  to  great  stiffness  of 
wrist  and  fingers.  But  if  the  hand  is  allowed  to  hang  down  with- 
out restraint,  this  will  not  occur,  and  its  weight  is  sufficient  to  hold 
the  end  of  the  ulna  in  its  place.  Any  use  the  patient  is  likely  to 
make  of  the  hand  or  fingers  is  not  apt  to  do  harm,  but  rather  good, 
b}'  preventing  false  ankylosis.  Three  weeks  is  all  that  is  necessary 
for  treatment. 

"  Colles'  fracture  is  apt  to  be  very  painful  until  restitution  of 
the  displaced  parts  is  complete.  When  this  is  done,  the  pain  and 
general  distress  rapidly  subside.  I  have  broken  over  many  wrist 
bones,  at  times  varying  from  a  few  weeks  to  six  months  after  the 
accident,  and  while  there  is  much  pain  and  soreness  from  the  new 
traumatism,  in  a  few  days  the  pain  begins  to 
subside,  and  finally  disappears  if  the  parts 
are  successfully  replaced.  It  is  not  wise  to 
break  over  the  bone  united  in  a  wrong  posi- 
tion later  than  six  months.  Nature  begins 
the  process  of  rectification,  which  she  is  able 
to  partially  secure  by  rounding  off  the  edges 
of  the  displaced  bone.  Of  course,  the  radius 
is  shortened  and  the  end  of  the  ulna  thrust 
downward  and  forward,  the  end  projecting 
about  a  half-inch  beyond  the  line  of  the  short- 
ened radius.  Sometimes  the  pain  is  severe 
and  constant,  from  the  strain  upon  a  filament 
of  the  ulnar  nerve.  Such  a  condition  is  best 
treated  by  removing  the  lower  end  of  the 
ulna  for  a  half-inch.  The  result  is  remark- 
ably gratifying.  If  there  is  a  compound  luxa- 
tion as  well  as  fracture,  careful  antiseptic  pre- 
caution must  accompany  the  reduction." 

The  foregoing  description  of  the  nature 
and  treatment  of  Colics'  fracture  leaves  little 
room  for  additional  discussion,  as  Moore's 
conception  of  its  mechanism  and  the  essential  points  in  treatment 
are  correct  and  in  full  accord  with  modern  surgery.  As  he  ver\' 
correctly  states,  the  line  of  fracture  in  a  typical  Colics'  fracture  is 
usually  nearer,  .seldom  further,  than  an  inch  from  the  articular  end 
of  the  bone.  The  line  of  fracture  is  usually  transverse  and  oblique 
from  the  palmar  to  the  dorsal  surface,  so  that  the  dorsal  side  of 
the  fragment  is  somewhat  larger  than  the  palmar.  The  fractured 
surface  of  the  lower  fragment  is  often  slightly  concave,  that  of  the 
upper,  convex.  The  direction  in  which  the  fracturing  force  is 
applied  and  the  line  of  fracture  are  such  as  to  tear  the  periosteum 
on  the  palmar  side,  while  a  bridge  of  periosteum  usually  connects 
the  lower  with  the  u[)i)er  fragment  on  the  dorsal  side.  If  the 
fracturing  force  is  continued  after  the  bone  is  broken,  it  results  in 
31 


Fig.  296. — Colles' 
fracture,  showing  impac- 
tion of  the  upper  into  the 
lower  fragment  (Hoffa). 


482  SPECIAL    FRACTURES. 

impaction  of  the  upper  into  the  lower  fragment,  which  may  fissure 
or  comminute  the  latter  if  the  penetration  is  a  deep  one  and  the 
incuneated  part  of  the  bone  of  considerable  size,  acting  like  a 
wedge. 

Impaction  always  results  in  more  or  less  crushing  of  the  spon- 
giosa  of  the  lower  fragment.  The  most  frequent  form  of  impac- 
tion consists  of  penetration  of  the  compacta  of  the  upper  frag- 
ment on  the  dorsal  side  into  the  spongiosa  of  the  lower  fragment 
on  the  opposite  side,  resulting  not  only  in  shortening,  but  also  in  a 
tilting  of  the  lower  fragment  backward,  displacements  which,  in 
typical  cases,  give  rise  to  the  silver-fork  deformity.  The  deviation 
of  the  hand  toward  the  radial  side,  caused  by  the  fracturing  force, 
immediately  after  the  radius  gives  way,  results  in  tearing  of  liga- 
ments on  the  ulnar  side,  the  triangular  cartilage,  and  partial  or 
complete  dislocation  of  the  lower  end  of  the  ulna.  The  importance 
of  this  complication  has  never  been  fully  recognized  by  authors, 
teachers,  and  the  mass  of  the  profession. 

In   rare  cases   the  line  of  fracture   is  very  oblique,  extending 


Fig.  297. — Colles'  fracture,  exhibiting  the  radial  deviation  of  the  hand. 

from  above,  on  the  radial  side,  downward  and  toward  the  ulnar 
side,  occasionally  extending  into  the  joint. 

Besides  the  injuries  at  the  lower  end  of  the  ulna  Ave  find,  as 
further  complications  in  this  fracture,  injuries  of  the  tendon  sheaths 
of  the  extensor  pollicis  brevis  and  adductor  pollicis  longus,  with 
extravasation  into  the  open  tendon  sheaths  and  the  fascia  surround- 
ing them.  It  is  in  cases  of  this  kind,  when  the  primary  swelling 
comes  on  quickly  and  reaches  considerable  dimensions,  that  the 
anatomic  landmarks  are  often  so  much  obscured  as  to  render  the 
diagnosis  very  difficult.  With  great  displacement  of  the  upper  frag- 
ment toward  the  palmar  side,  serious  injury  of  the  soft  tissues  on 
this  side  of  the  fracture  may  still  further  complicate  the  case  and 
add  to  the  diagnostic  difficulties. 

The  most  important  symptoms  of  Colles'  fracture  are  :  Pain 
and  tenderness  that  correspond  to  the  location  and  line  of  frac- 
ture and  that,  in  the  event  of  no  displacement,  serve  as  the  only 
or,  at  least,  as  the  most  important  witnesses  of  the  existence 
of  the    fracture;    when    displacement  to  any  considerable    extent 


COLLES'     FRACTURE. 


483 


has  occurred  the  cliaracteristic  silver-fork  deformity  leaves  no 
doubt  as  to  the  location  of  the  fracture.  The  degree  of  func- 
tional disability  corresponds  ^vith  the  extent  of  the  displacement 
The  power  of  the  hand  is  diminished  or  almost  enbrely  lost,  and 
pronation  and  supination  are  impaired  or  entirely  suspended.  In 
the  tvpical  deformitv  two  abnormal  prominences  are  seen,  one  on 
the  dorsal  side,  corresponding  with  the  lower  fragment  displaced 
in  that  direction,  and  one  on  the  flexor  side,  the  palmar  margm  of 
the  upper  fragment.      In  the  presence  of  considerable  swelling  ot 


ri„    298.-A,  Colles'  fracture,  lateral  illumination  ;  B,  Colles'  fracture,  illumination 

from  dorsal  side. 

the  soft  tissues  these  prominences  are  obscured,  but  can  always  be 
felt  on  making  firm  digital  palpation.  In  conscquaicc  of  the  radial 
deflection  of  the  loiver  fragment  the  axis  of  the  forearm  corresponds 
with  that  of  the  long  axis  of  the  fourth  metacarpal  bone,  a  deformity 
that  imparts  to  the  forearm  and  hand  the  outlines  of  a  bayonet  I  he 
normal  dorsal  convexity  of  the  radius  is  also  lost  by  the  displacement 
of  the  laiver  fragment,  something  that  can  be  determined  even  in  cases 
in  which  the  deformity  is  slight.  Suggillation  is  most  marked  on  the 
volar  side.    Abnormal  mobility  and  crepitus  are  usually  absent,  owing 


484  SPECIAL    FRACTURES. 

to  the  existence  of  impaction  to  a  greater  or  less  extent.  If  the  dorsal 
branch  of  the  uhiar  nerve  is  compressed  by  the  preternaturally 
prominent  head  of  the  uhia,  the  patient  usually  makes  complaint 
of  pain  along  the  inner  side  of  the  wrist-joint,  which  often  extends 
to  the  fourth  and  fifth  metacarpal  interspaces  and  respective  fingers. 
Paralysis  in  the  territories  supplied  by  branches  of  the  median 
nerve  below  the  seat  of  fracture  is  met  in  rare  cases  in  which  the 
upper  fragment  is  displaced  to  any  considerable  extent  toward  the 
palmar  side.  ///  sprains  of  the  wrist-joint  the  pain  and  tenderness 
correspond  with  the  location  of  the  Joint ;  in  fractures,  with  a  point 
always  within  a  distance  of  from  o7ie  to  one  and  one-lialf  inches. 

Dislocation  of  the  carpus  is  an  exceedingly  rare  injury;  Colles' 
fracture,  on  the  other  hand,  is  very  common.  The  exact  location 
of  the  dorsal  prominence  and  the  location  of  pain  and  tenderness 
will  serve  a  useful  purpose  in  the  differential  diagnosis  between  these 
two  injuries. 

In  reference  to  the  prognosis  it  may  be  said  that  the  functional  re- 
sidt  depends  more  on  the  completeness  of  the  reduction  than  on  the 

mechanical  treatment  calcu- 
lated to  maintain  retention. 
A  slight  dorsal  displacement 
often  remains  as  an  evidence 
of  the  existence  of  a  Colles 
fracture  in  the  practice  of  the 
most  competent  and  pains- 
taking surgeons,  in  conse- 
quence of  more  or  less  critsh- 
incr  of  the  spongiosa  in  the 

Fig.  299. — Colles'  fracture,  with  great  dis-        ,  ^      ,   -f .  f        j-r  .i  ,        r 

placement  of   the    upper   fragment    toward    the       tOZVer  jragment.      Ij  tlie  StlO- 

palmar  side  (Hoffa).  luxation   of  the  lUna  is  not 

entirely  corrected  at  the  time 
the  reduction  is  made,  a  permanent  radial  displacement  of  the  hand 
is  the  inevitable  residt.  Even  if  the  fracture  heals  with  marked 
deformity,  ultimate  satisfactory  restoration  of  function  is  the  ride. 
Speedy  and  perfect  restoration  of  function  may  be  confidently  ex- 
pected in  cases  in  which  the  nature  of  the  injury  is  recognized 
and  perfect  reduction  effected,  and  retention  of  the  fragments  in 
their  normal  position  maintained  tcntil  the  fracture  has  healed 
by  bony  union.  The  functional  residt  is  enhanced  by  resorting  to 
methods  of  immobilization  that  do  not  inteifere  with  the  free  move- 
ments of  the  fingers  from  the  moment  the  injury  was  sustained.  The 
complicating  injuries  of  the  adjacent  wrist-joint,  tendon  sheaths,  and 
other  important  paraosteal  structures  must  be  taken  into  careful 
consideration  in  predicting  the  probable  result  of  the  injury.  Pre- 
mature use  of  the  limb,  as  zvell  as  too  prolonged  restraint,  is  in  the 
way  of  obtaining  a  speedy  and  satisfactory  functional  result.  The 
retentive  dressiyig  shoidd  never  interfere  zvith  the  free  movements  of  the 
fingers,  but  the  immobilization  of  the  hand  for  three  or  more  weeks 


COLLES'     FRACTURE.  485 

constitutes  an  important  part  of  the  treatment  most  conducive  to  an 
ideal  functional  result.  The  most  important  part  of  the  successful 
treatment  of  Colics  fracture  is  perfect  reduction.  It  is  this  part  of 
the  treatment  that  is  so  often  defective,  owing  to  uncertainty  of 
diagnosis  or  inefficient  efforts  to  effect  perfect  reduction.  In  frac- 
tures in  Colles'  line  without  displacement,  Sir  Astle}^  Cooper  recom- 
mended, in  the  treatment,  the  employment  of  a  compress,  applied 
below  the  seat  of  fracture  and  retained  with  a  strip  of  adhesive 
plaster,  and  placing  the  forearm  in  a  sling  in  such  a  way  that  the 
line  of  fracture  would  correspond  with  the  anterior  margin  of  the 
mitella. 

The  method  of  reduction  under  the  influence  of  a  general  anes- 
thetic, described  by  Moore,  is  the  one  to  be  relied  upon  in  Colles' 


Fig,  300. — Dressing  for  Colles'  fracture. 

fracture  with  displacement.  He  has  well  said  that  it  requires  often 
the  full  strength  of  the  surgeon  to  effect  the  same.  Extension  and 
countcrextension,  i)ressure,  and  ulnar  flexion  of  the  hand  are  the 
means  by  which  perfect  reduction  should  be  aimed  at  and  effected. 
Imperfect  rediictioit  always  means  a  result  unsatisfactory  alike  to 
patient  and  physician,  regardless  of  the  care  that  may  be  exercised 
later  in  the  mechanical  treatment  of  the  fracture.  I  Vithout  complete 
reduction  the  subsequent  treatme7it  ivill  prove  unsatisfactory  in  yield- 
ing an  ideal  functional  residt. 

After  reduction  has  been  effected,  the  next  rule  is  to  resort  to 
retentive  measures  that  do  nf)t  interfere  with  the  free  movements  of. 
the  fingers.  Moore  relies  on  compress,  circular  .strip  of  adhesive 
pla.ster,  and  mitella  in  maintaining  coaptation  of  the  fragments,  and 


486  SPECIAL    FRACTURES. 

undoubtedly  in  his  hands  this  treatment  has  yielded  ideal  results. 
The  laity,  as  well  as  the  mass  of  the  profession,  however,  would  con- 
sider such  treatment  short  of  the  indications  presented  by  the  injury. 
Long  ago  I  grasped  the  principles  laid  down  by  Moore  in  the  treat- 
ment of  Colles'  fracture,  but  I  have  always  deemed  it  advisable  to 
support  it  by  mechanical  treatment  that  would  immobilize  the  hand 
and  thus  add  to  the  more  nearly  perfect  immobilization  of  the  lower 
fragment. 

Ready-made  splints  of  any  kind  are  out  of  place  here.  I 
apply  Moore's  dressing,  and,  in  addition,  two  well-padded  splints, 
anterior  and  posterior,  the  former  extending  from  the  elbow  to  the 
wrist,  the  latter  from  the  elbow  to  the  base  of  the  fingers.  These 
are  held  in  place  by  three  strips  of  adhesive  plaster,  one  below  the 
thumb,  the  second  over  the  lower  fragment,  and  the  third  below 
the  elbow.  The  second  strip  is  placed  over  the  ulnar  compress. 
The  whole  dressing  is  held  in  place  by  a  gauze  roller  extending 
from  the  base  of  the  fingers  to  the  elbow.  This  dressing  will 
answer  a  most  useful  purpose  for  two  weeks,  when  it  can  be  advan- 
tageously replaced  by  a  dorsal  plastic  splint  extending  from  the 
base  of  the  fingers  to  the  elbow-joint.  It  is  my  opinion  that,  in 
adults,  immobilization  of  the  lower  fragment  by  an  appropriate 
dressing  should  be  continued  for  a  period  of  at  least  four  weeks  ; 
in  other  words,  until  bony  consolidation  is  firm  enough  to  make  an 
external  mechanical  support  superfluous.  The  forearm  should  be 
placed  in  a  sling,  in  a  position  half-way  between  pronation  and  su- 
pination, until  the  process  of  repair  is  completed.  Active  and  pas- 
sive motion  after  this  time,  aided  by  massage  and  faradization,  are 
well  calculated  to  insure  speedy  restoration  of  function. 

FRACTURES  OF  THE  SKULL. 

There  is,  perhaps,  no  department  in  surgeiy  in  which  the  general 
practitioner  is  more  interested  than  in  fractures  of  the  skull.  This 
class  of  injuries  usually  comes  for  first  treatment  to  the  physician, 
and  not  to  the  professional  surgeon.  The  subject  is  a  most  im- 
portant one,  because  life  and  the  future  well-being  of  the  patient 
often  depend  upon  prompt,  rational  surgical  treatment,  based  on  a 
correct  diagnosis.  In  the  management  of  such  cases  it  is  important 
to  remember  that  the  injury  that  produces  the  fracture  of  the  skull 
frequently  causes,  at  the  same  time,  visceral  intracranial  lesions, 
which  constitute  the  main  reason  for  life-saving  operations.  The 
extent  of  the  fracture  is  of  less  consequence,  so  far  as  the  fate  of  the 
patient  is  concerned,  than  the  existence  of  complicating  intracranial 
injuries.  An  extensive  comminuted  closed  fracture  of  the  skull 
without  the  coexistence  of  serious  intracranial  complications  is  an 
injury  from  which  the  patient  recovers  in  the  usual  course  of. time 
and  without  any  remote  ill  results.  On  the  other  hand,  a  limited 
fracture  with  rupture  of  the  middle  meningeal  artery  may  result  in 
death  in  the  course  of  a  few  hours,  from  cerebral  compression,  unless 


FRACTURES    OF    THE    SKULL. 


487 


the  immediate  cause  of  death  is  averted  by  prompt  operative  inter- 

fp  TG  n  c  c 

The  crreatest  source  of  danger  in  fractures  of  the  skull  is  a  com- 
plicatinA-ound  of  the  overlying  soft  tissues,  which  communicates 
with  the  contents  of  the  skull  through  the  cranial  defect.     A  Punc- 
tured fracture  of  the  skull  is  always  a  grave  mjury,  as  of  all  frac- 
tures of  the  skull  it  is  most  likely  to  be  followed  by  nifection.     A 
fracture  of  the  skull  is  said  to  be  complete  if  the  hne  of  fracture  m- 
volves  both  the  external  and  the  internal  table— that  is,  the  entire 
thickness  of  the  skull.      In  incomplete  fractures  of  the  skull  only 
one  of  the  tables  is  fractured.      A  vulnerating  implement  of  limited 
dimensions,  directed  against  the  skull  with  sufficient  force  to  frac- 
ture either  the  external  or  the  internal  table,  results  in  a  character- 
istic injury  at  the  point  of  impact.      If  only  the  external   table  is 
fractured,  a  limited  depression,  corresponding  m  size  to  the  circum- 
ference   of  the    frag- 
ment, is  produced  by 
crushing    of  the   un- 
derlying    diploe.      If 
the  external  table  re- 
mains  intact,  the   in- 
ternal table  gives  way 
immediately  under- 
neath    the     point     of 
impact,    and    the    de- 
tached fragment  is  left 
with  few  or  no  vascu- 
lar   connections,   act- 
ing the  part  of  a  for- 
eign aseptic  substance 
until  it  enters  into  new 
vascular  connections. 
The  existence  of  frac- 


Fig.  301.— Fissure  of  cranial  vault  (Hoffa). 


ture  of  the  internal  table  has  recently  been  satisfactorily  demon- 
.strated  on  the  living  subject  by  the  u.se  of  the  X-ray  I^rom  a 
sur-ical  standpoint  it  is  important  to  divide  fractures  of  the  skull 
anatomically  into  fractures  of  the  vault  and  base,  the  former  bemg 
accessible  to  direct  surgical  intervention,  the  latter  remaining 
larcrely  inaccessible  to  direct  surgical  treatment. 

In  fractures  of  the  vault,  the  seat  of  injury  is  within  range  of 
direct  examination,  and  the  exact  location,  nature,  and  extent  of  the 
fracture  can  usually  be  determined  by  the  signs  presented.  A 
fissure  is  a  linear  fracture,  and  as  an  i.solatcd  single  injury  occurs 
most  frequently  at  the  base  of  the  skull,  in  con.sequence  of  indirect 
application  of  force.  In  open  fractures  of  the  vault  hair  and  other 
foreign  substances  are  not  infreciucntly  found  imprisoned  in  the  fis- 
sure having  entered  at  the  moment  the  fracture  occurred,  the  open 
fissure   closing   upon    them  as  soon  as  the  elasticity  of  the   skull  is 


488 


SPECIAL    FRACTURES. 


restored,  the  fractured  bone  returning  to  nearly  its  normal  shape 
and  position.  A  fracture  may  be  extensively  comminuted  with 
little  or  no  depression,  and  the  depressed  fragment  of  a  limited 
fracture  may  give  rise  to  grave  symptoms  of  cerebral  compression. 
In  fissured  fractures  of  the  skull  a  "  cracked-pot  "  sound  is  elicited 
on  percussion.  The  same  force  that  fractures  the  skull  also  causes 
the  depression.  The  depressed  fragment  or  fragments  frequently 
correspond  in  size  and  shape  to  the  contour  of  the  vulnerating  im- 
plement, a  matter  of  great  importance  in  forensic  medicine.  Mus- 
cular action  has  nothing  whatever  to  do  with  the  displacement  of 
the   fragments.      Contusion   of  the  scalp  is  occasionally  mistaken 

for  a  depressed  frac- 
ture, and  vice  versa. 
The  crushing  of  the 
soft  tissues  underneath 


the    point 
and     the 
edematous 


of  impact, 
subsequent 
wall     sur- 


rounding the  contused 
area,  in  many  respects 
resemble  the  appear- 
ance of  a  depressed 
fracture,  and  it  is  only 
by  a  careful  examina- 
tion of  the  local  signs 
and  by  a  recourse  to 
all  diagnostic  resources 
that  the  surgeon  is  en- 
abled to  make  a  dif- 
ferential diagnosis  be- 
tween this  condition 
and  a  depressed  frac- 
ture. In  contusion  of 
the  scalp  the  surface 
of  the  skull  remains 
smooth  and  the  level 
everywhere  normal, 
conditions  revealed  by  deep  palpation  and  confirmed  in  doubtful 
cases  by  exploration  with  a  stout  aseptic  steel  needle  (akidopei- 
rasty).  This  diagnostic  resource  often  is  found  useful  in  determin- 
ing the  existence  of  a  depression  and  in  locating  the  line  of  fracture. 
In  fractures  produced  by  contre-coup,  or  so-called  counterstroke, 
the  seat  of  injury  is  always  at  a  point  opposite  to  where  the  force 
was  applied. 

Symptoms. — The  escape  of  cerebrospinal  fluid  through  the 
wound  or  underneath  the  scalp  is  a  positive  evidence  of  the  exis- 
tence of  a  fracture  and  laceration  of  the  meninges.  If  the  cerebro- 
spinal fluid  escapes  through  the  external  meatus,  it  is  a  reliable 


Fig.  302.- 


-Extensive  fracture  at  the  base  of  the  skull 
(Hoffa). 


FRACTURES    OF    THE    SKULL.  489 

proof  of  laceration  of  the  membrana  tympani  and  fracture  at  the 
base  of  the  skull.  If  any  doubt  exists  as  to  the  source  of  the  serous 
discharge,  a  chemic  test  will  yield  results  that  will  decide  between 
a  ruptured  tympanum,  followed  by  the  escape  of  fluid  from  the 
middle  ear,  and  a  fracture  at  the  base  of  the  skull.  As  a  rule,  it  is 
not  difficult  to  recognize  the  existence  of  a  depressed  fracture  of 
the  vault  of  the  skull,  even  in  the  absence  of  any  brain  symptoms. 
In  fractures  at  the  base  of  the  skull  displacement  of  the  fragments 
to  any  considerable  extent  seldom  takes  place,  except  in  circular 
fracture  around  the  foramen  magnum,  and  in  this  event  sudden 
death  from  compression  of  the  medulla  oblongata  by  the  displaced 
fragments,  caused  by  either  the  fracturing  force  or,  later,  by  the 
patient  assuming  the  sitting  position  before  union  has  taken  place. 
The  existence  of  focal  symptoms  is  of  special  diagnostic  value  in 
fractures  at  the  base  of  the  skull.  Fractures  in  the  neighborhood 
of  the  thalamus  opticus  and  optic  tracts  are  sometimes  followed  im- 
mediately by  loss  of  vision  in  one  or  both  eyes,  caused  by  laceration 
of  the  brain  or  of  the  optic  nerves.  Facial  paralysis  and  loss  of 
hearing  immediately  following  the  injury  point  to  fracture  of  the 
petrous  portion  of  the  temporal  bone.  Hemorrhage  from  the  nose 
or  the  nasopharynx  following  an  injury  to  the  skull  is  very  sug- 
gestive of  fracture  at  its  base.  Fxophthalmos  appearing  a  short 
time  after  the  injury  indicates  fracture  of  the  orbital  plate  of  the 
frontal  bone.  Ecchymosis  of  the  eyelids  and  conjunctiva  points 
to  a  similar  injury  or  to  fracture  of  the  sphenoid  bone  ;  and  the 
appearance  of  an  ecchymosis  of  the  mastoid  region  several  days 
after  the  accident  is  a  late  evidence  of  a  fracture  in  the  region  of 
the  mastoid  process  of  the  temporal  bone.  In  gunshot  and  punc- 
tured fractures  at  the  base  of  the  skull  the  location  and  direction  of 
the  wound  and  the  nature  of  the  discharge  must  be  taken  into  careful 
consideration  in  formulating  a  diagnosis,  more  especially  in  cases  in 
which  no  focal  s\'mptoms  are  present.  Fracture  of  the  internal  table 
of  the  skull  as  an  isolated  injury  is  recognized  more  frequently  in  the 
postmortem  room  than  at  the  bedside.  The  focal  symptoms  and  the 
.seat  of  injury  may  suffice  in  locating  the  lesion,  but  the  differential 
diagnosis  between  this  fracture,  cerebral  contusion,  and  intracranial 
hemorrhage  must  always  remain  doubtful.  Improved  radiography 
may,  in  the  future,  prove  to  be  the  most  important  diagnostic  re- 
source in  establishing  the  existence  of  this  injury,  as  well  as  in  the 
recognition  of  other  fractures  of  the  skull  that  are  inaccessible  to 
direct  examination. 

The  cerebral  lesions  that  so  often  comi)]icate  fractures  of  the 
skull  sometimes  aid,  and  at  other  times  obscure,  the  diagnosis.  Con- 
cussion, so  constantly  present  if  the  fracture  is  produced  by  the 
aj)[)lication  of  blunt  force,  always  overshadows  focal  symptoms, 
which  often  appear  later,  after  the  patient  has  recovered  from  the 
immediate  effects  of  the  injury.  In  punctured  fractures  .symptoms 
of  concussion  are   usually  slight  or  entirely  absent,  and  the  focal 


490 


SPECIAL    FRACTURES. 


symptoms,  if  there  are  any,  appear  promptly.  The  existence  and 
location  of  a  cerebral  contusion  become  apparent  only  after  the 
effects  of  the  concussion  have  subsided.  The  characteristic  clinical 
feature  of  intracranial  hemorrhage  is  a  gradual  but  progressive  in- 
crease in  the  severity  of  the  focal  symptoms  as  long  as  the  hemor- 
rhage continues  ;  on  the  other  hand,  the  maximum  symptoms  of 
concussion  present  themselves  immediately  after  the  injury,  and  of 
contusion  as  soon  as  the  patient  recovers  from  the  effects  of  the 
concussion.  In  compound  fractures  of  the  cranial  vault  very  little, 
if  any,  difificuhy  will  be  experienced  in  ascertaining  the  existence  of 
a  fracture.  The  escape,  from  the  wound,  of  cerebrospinal  fluid  and 
brain  tissue  leaves  no  doubt  as  to  the  nature  of  the  injury.  The 
examination  of  the  wonnd,  zvith  a  view  to  determining  the  exact  loca- 
tion and  extent  of  the  fractui^e,  and  the  search  for  visceral  injuries 
must  be  conducted  with  the  most  pedantic  care,  for  the  purpose  of 
guarding  against  zvoiind  infection.  Every  accidental  woimd  must  he 
regarded  as  an  infected  zvotmd,  but  the  superficial  infection  amenable 
to  successfid  disinfection  may  be  made  deep  and  inaccessible  by  careless, 
reckless  exploration  of  the  wound  for  diagnostic  purposes.  The  sur- 
geon should  realise  to  the  fullest  extent  the  additional  responsibilities 
thrown  upon  him  by  modern  aseptic  surgery  in  the  management  of 
such  cases.  The  fate  of  the  patient  is  often  decided  by  the  degree  of 
care  exercised  in  the  examination  and  treatment  of  the  complicating 
wound.  Recogrnzvig  the  force  of  this  statement,  it  is  apparent  that 
haste  tinder  such  circumstances  is  inexcusable,  if  not  almost  criminal. 
No  digital  or  instrumental  examination  of  the  wound  should  be  made 
until  the  necessary  preparations  have  been  completed.  The  examina- 
tio7t  of  such  a  wound  with  a  dirty  finger  or  an  unclean  instrument  is 
responsible  for  innumerable  deaths  from  septic  intracranial  affections, 
many  of  which  might  have  been  prevented  by  making  the  examination 
under  strict  aseptic  precautions.  Early  mistakes  made  in  assuming 
charge  of  such  cases  frequently  result  in  complications  that  are  not 
amenable  to  later  and  better  directed  treatment.  Sins  of  commis- 
sion and  omission  bring  the  same  dire  results  in  such  cases. 

In  every  compound  fracture  of  the  skull  involving  the  hairy 
scalp  the  examination  should  be  preceded  by  shaving  and  disinfec- 
tion of  the  entire  scalp.  The  wound  itself  must  be  subjected  to  a 
superficial  disinfection  before  it  is  touched.  Pouring  peroxid  of 
hydrogen  into  the  wound  and  flushing  it  with  a  2  ^  per  cent,  solu- 
tion of  carbolic  acid  will  prepare  it  properly  for  exploration  with 
a  thoroughly  disinfected  finger  or  sterile  instruments.  Foreign 
bodies  are  searched  for  and  removed,  and  antiseptic  irrigation  is 
repeated  from  time  to  time  as  the  exploration  is  extended.  By 
following  these  directions  the  wound  is  in  a  condition  for  safe  sur- 
gical intervention  at  the  completion  of  the  examination. 

Prognosis. — The  prognosis  in  fractures  at  the  base  of  the  skull 
is  always  grave,  owing  largely  to  the  inaccessibility  of  the  compli- 
cating intracranial  lesions  to  direct  surgical  treatment,  and,  in  case 


FRACTURES   OF   THE   SKULL.  49' 


the  fracture  is  con,pound,  to  the  difficulty  in  preventing  infection 
through  the  wound  from  without.     The  danger  ui  all  fractures  of 
ru  depends  largely  on  the  location  and  extent  o  the  v.sce^a 
lesions  and  intracranial  hemorrhage,  and,  if  the  fiactuie  is  com 
nound  infection  of  the  wound.     Wound  infection  is  prone  to  result 
du"str'o  s[y  if  the  meninges  of  the  brain  are  ruptured,  as  when  the 
h  ec tic"   reiches  the  pia  and  surface  of  the  brain  it  is  very  liable  to 
p"d  rapidly,  and  a's  surgical  treatment  has  ^ly  a  Imi.^d  co  - 
tiol  over  this  affection,  the  patient  dies  m  a  few  da>s  homj-ep^^ 
eo  omeninaitis.     The  mortality  of  fractures   at  the  base   of  the 
s?uU  co?nptoted  by  an  external  wound  has  been  materially  reduced 
bv     eat        the  wounds  under  antiseptic  precautions  as  far  as  their 
nature  ad  location  will  permit.     The  extent  of  brain  mjury  ha    a 
weighty  bearing  on  the  prognosis.     If  the  bram  wound  implicates 
moo    Lit    nerve    centers,  death    may   ensue    in    consequence    of 
oaSv^is  of  vital  nerves  ;  on  the  other  hand,  if  the  wound  affects 
fess  tapor  ant  locations,  large  masses  of  bram  tissue  have  been 
lost    "v  °he  injury  or  were   later   removed,  without  any  serious 
mmecUate  or  remote  consequences.     In  compound  fractures  the 
™o"nosi    rests    largely    on    the  existence  or  absence  o     wound 
^,fection— "narded    in    the   former   case,    favorable    in    the    latter 
n  ta  ce     ft  is  almost  impossible  to  predict  the  remote  consequences 
of  fractures  of  the  skull      Vertigo,  headache,  insanity,  paralysis, 
and  en  lepsy  are  only  some  of  the  remote  results  of  such  injuries. 
Fxperie'rce  has  shown  that   these    late  complications  are  cau  ed 
more   requently  by  the  visceral  lesions  of  the  cranial  contents  than 
rvdiawes  in  the  shape  of  the  skull  or  by  altered  dimensions  in 
?he  cralTcTv  y  as  is  shown  only  too  conclusively  by  the  many 
ltr:tsults;fo,,ow.ng  trephining^ 

1  ve  V  a' °ic  formation  of  an  exuberant  provisional  callus,  as  found 
so  f^quen  y  n  the  healing  of  fractures  of  the  long  bones,  could 
not  fan  grcaUy  to  increase  the  frequency  of  remote  comphca tions. 
Fiivdly  may  well  be  said,  in  tlie  language  of  an  eminent  sui- 
geon  of  the  distan't  past :  "  No  injuries  of  the  skull  are  too  extensive 
To  be  despaired  of,  and  none  too  slight  to  be  ignored. 

Treatment—The  mechanical  treatment  of  fractures  of  Ae  -j^"' 
is  liniite.1  to  cases  in  which  it  becomes  necessary  to  elevate  oi 
"em         iep^esSd  fragments.     Fixation  of  the  f-gn-nts  is  never 
required,  owing  to  the  absence  of  displacing  f-"^'  ,  OP^J^^^^ 
treatment  further  than  this  may  become  "ecc^ssa,•y  foi      e  pnipo^^^^^ 
of  removing  foreign  bodies   and  "Pos-g  and     ul^  tug  to  d   ec^ 
fr..ntmcnt  fM-avc   ntracraiiial  lesions.      Kcst  in  oeu  wiui  l 
anSed  »^tion  must  be  enforced  in  all  cases  until  the  dang  . 
arising  from' complications  has  pas.sed,  and  in  fracture    at  the  base 
ofthc^skullunti,    he  injury  tothebonehase^^^^^ 
for  at  least  from  four  to  six   weeks.       l  nc   ^cneia. 


492 


SPECIAL    FRACTURES. 


have  for  its  object  the  guarding  against  a  harmful  blood  supply  to 
the  brain,  which  includes  a  limited  nonstimulating  diet,  the  admin- 
istration of  cathartics,  and  the  application  of  cold  to  the  head  in  the 
form  of  a  cold  coil  or  an  ice-bag.  The  application  of  cold  should  be 
begun  as  soon  as  reaction  has  been  established,  and  continued  until 
the  tendency  to  cerebral  congestion  has  subsided.  If  the  ice-bag 
becomes  a  source  of  discomfort  to  the  patient,  a  moist  compress  is 
placed  between  it  and  the  scalp.  Mental  rest  is  as  essential  as 
physical  repose  in  placing  the  injured  parts  in  the  most  favorable 
condition  for  a  speedy  and  satisfactory  repair.  Absolute  quietude 
in  the  room  and  exclusion  of  light  during  the  first  few  days  must 
be  rigidly  enforced.  If  the  patient  is  unconscious,  aseptic  syste- 
matic catheterization  must  be  instituted  at  the  proper  time  and  con- 
tinued until  the  patient  recovers  control  over  the  bladder.  Blood- 
letting, leeching,  and  cupping,  so  constantly  employed  until  a  few 
years  ago  with  the  hope  of  diminishing  the  liability  to  intracranial 
infection,  are  no  longer  resorted  to,  since  the  real  causes  of  infection 
have  been  discovered  and  satisfactorily  demonstrated.  The  local 
treatment  in  fractures  at  the  base  of  the  skull  is  limited  to  cases  in 
which  the  fracture  is  compound,  and  consists  in  attempts  to  prevent 
infection  of  the  wound.  If  the  wound  consists  of  a  ruptured  tym- 
panum, the  external  meatus  is  disinfected,  dried,  freely  dusted  with 
the  borosalicylic  powder,  and  lightly  packed  with  aseptic  absorbent 
cotton,  which  is  removed  as  soon  as  it  becomes  saturated,  when  the 
meatus  is  repacked  with  fresh  cotton.  In  fractures  at  the  base  of 
the  skull  communicating  with  the  nasal  cavities  or  the  nasopharynx 
it  is  advisable  to  disinfect  the  mucous-  surface,  so  far  as  this  can  be 
done,  with  mild  antiseptic  solutions,  and  pack  with  a  strip  of  iodo- 
form gauze.  In  punctured  fractures  at  the  base  of  the  skull,  if  no 
foreign  bodies  are  lodged  in  the  wound,  an  antiseptic  dressing  is 
applied  and  the  wound  disturbed  as  little  as  possible. 

The  much-discussed  subject  of  trephining  in  recent  fractures  of 
the  skull  can  be  quite  briefly  disposed  of  in  the  light  of  modern  sur- 
gery. It  is  a  very  old  surgical  procedure  and  has  had  an  extended 
trial.  During  the  preantiseptic  era  of  surgery  the  operation  was 
so  often  followed  by  infection  of  the  wound  and  of  the  cranial  con- 
tents that  Stromeyer  entered  his  protest  against  it,  and  most  of  the 
surgeons  of  his  time  followed  his  example  and  eliminated  it  from 
the  list  of  legitimate  operations.  With  the  introduction  of  antisep- 
tic and  aseptic  surgery  the  operation  again  came  rapidly  into  favor, 
and  at  the  present  time  the  pendulum  swings  in  an  opposite  direc- 
tion. Many  surgeons  of  large  experience  entertain  decided  convic- 
tions regarding  the  propriety  and  advisability  of  operative  interfer- 
ence in  all  fractures  of  the  vault  of  the  skull.  This  extreme  position 
is  not  tenable,  even  at  the  present  time,  as  we  can  not  always  rely 
on  the  aseptic  precautions  absolutely  to  protect  the  wound  against 
infection.  The  surgeon  who  converts- a  closed  fracture  of  the  skull 
into  an  open  one  without  adequate  cause  assumes  a  great  respon- 


FRACTURE    WITH    DEPRESSION.  493 

sibility.  The  present  technic  of  asepsis  does  not  furnish  absolute 
protection  against  infection,  even  in  the  best-equipped  hospitals,  and 
with  all  the  advantages  to  be  gained  from  the  cooperative  work  of 
well-trained  and  experienced  assistants  and  nurses.  If  this  be  true 
of  hospital  practice,  it  is  easy  to  imagine  how  much  more  frequently 
infection  would  occur  in  emergency  surgery  in  private  practice, 
where  the  facilities  for  asepsis  are  often  very  limited  and  operations 
have  to  be  performed  without  the  aid  of  skilled  assistants.  But, 
besides  the  dangers  of  a  possible  infection,  there  are  other  reasons 
why  operative  interference  should  not  be  resorted  to  indiscriminately 
in  all  cases  of  fracture  of  the  cranial  vault.  Subcutaneous  fractures 
with  little  or  no  depression  are  speedily  repaired,  and  are  seldom  fol- 
lowed by  cerebral  disturbances  of  any  kind  that  could  be  attributed 
to  the  fracture  per  se.  It  has  already  been  stated  that  the  remote 
complications  of  fractures  are  more  frequently  caused  by  complicat- 
ing intracranial  lesions  than  by  the  fiiacture  itself,  and  it  is  not  always 
possible  to  correct  these  defects  by  the  operation,  even  if  discovered 
at  the  time,  to  say  nothing  of  injuries  that  are  inaccessible  or  that 
are  overlooked. 

Conservatism  in  the  treatment  of  fractures  of  the  skull  is  to  be 
recommended  more  particularly  in  the  case  of  children.  I  have 
seen  several  cases  of  depressed  fracture  of  the  skull  in  children 
in  which,  under  conservative  treatment,  the  depression  disappeared 
entirely  during  the  second  week.  Spontaneous  replacement  of  the 
fragments  not  infrequently  occurs  from  the  cerebral  pressure,  after 
the  fragments  become  loosened  by  the  softening  and  absorption  of 
the  spiculse  of  bone  that  at  first  interlock  the  fractured  surfaces. 

Trephining  of  the  skull  must  be  reserved  for  the  following  frac- 
tures of  the  skull :  (i)  Subcutaneous  fractures  in  adults,  with  marked 
depression  ;  (2)  subcutaneous  fractures  attended  by  focal  symptoms  ; 
(3)  all  compound  fractures,  including  punctured  and  gunshot  frac- 
tures ;  (4)  fractures,  compound  and  subcutaneous,  complicated  by 
hemorrhage  from  the  middle  meningeal  artery. 

Fracture  with  Depression. — No  surgeon  would  hesitate  for  a 
moment  to  resort  to  operative  treatment  in  cases  of  depressed  frac- 
ture of  the  skull  in  which  the  depression  is  deep  enough  to  cause 
cerebral  compression.  The  s^me  course  of  treatment  is  indicated  in 
cases  in  which  the  depression  is  marked,  and  in  which  the  fracture 
has  caused  no  immediate  or  focal  symptoms.  In  such  instances  the 
operation  is  a  justifiable  propliylactic  precaution  against  remote 
complications  that,  in  the  course  of  time,  might  develop  in  conse- 
quence of  tiie  irritation  produced  by  the  permanently  displaced 
fragments.  The  trephine  should  never  be  used  in  the  elevation  of  a 
depressed  fracture  of  the  skull.  All  that  is  necessary  in  the  mechan- 
ical treatment  of  such  cases  is  to  make  a  cranial  defect,  with 
chisel  and  hammer,  nearest  the  most  depressed  part  of  the  fracture, 
and  only  large  enough  to  permit  the  in.sertion  of  an  elevator  under- 
neath the  depressed  bone,  with  which  the  fragment  or  fragments  are 


494 


SPECIAL    FRACTURES. 


raised  to  their  normal  level.  The  wound  is  enlarged  sufficiently  to 
expose  the  whole  depressed  area,  then,  at  a  point  where  the  depres- 
sion is  deepest,  the  margin  of  the  cranial  defect  is  chiseled  away  for 

the   insertion  of 

an  elevator.  If 
the  fracture  is 
subcutaneous, 
the  seat  of  in- 
jury is  exposed 
by  raising  a 
flap,  with  the 
base  directed 
downward,  and 
large  enough 
to  expose  the 
whole  depressed 
area.  As  the  in- 
ternal table  is 
always  fractured 
more  extensive- 
ly than  the  ex- 
ternal, the  cra- 
nial defect  made 


Fig.    303. — Enlarging  the  wound  preparatory  to  operation  for  a 
compound  depressed  fracture  of  the  skull. 


with  the  chisel  must  extend  somewhat  beyond  the  margin  of  the 
depressed  fragment,  for  the  insertion  of  the  elevator.  Kocher's 
director  is  a  very  safe  and  useful  instrument  for  this  purpose.  In 
using  it  as  a  lever 
the  margin  of  the 
cranial  defect  be- 
comes the  fulcrum, 
the  hand  the 
power,  and  the  de- 
pressed fragment 
the  weight.  In 
raising  the  frag- 
ment the  tips  of 
the  left  index-  and 
the  middle  finger 
are  placed  over  the 
depression,  steady- 
ing the  fragment  as 
it  is  being  slowly 
elevated.  This  is 
done  for  the  pur- 
pose of  preventing 
any  loss  of  bone,  and  to  determine  with  accuracy  the  completion 
of  the  elevation  of  the  depression.  The  fragments  must  be  raised 
to  their  normal  level  before  the  elevator  is  removed.      Every  frag- 


Fig.  304. — Exposure  of  seat  of  fracture. 


FRACTURE    WITH    DEPRESSION. 


495 


mcnt,  even  if  completely  detached,  vinst  be  saved  and  placed  in  proper 
position.  If  the  external  wound  is  a  lacerated  or  crushed  one,  it 
is  transformed,  as  nearly  as  can  be  done,  into  an  incised  wound  by 
trimming  the  margins.  Whenever  possible,  the  seat  of  fracture  is 
covered  with  the  pericranium  and  skin.  If  the  former  is  detached 
from  the  skin,  it  should  be  sutured  separately  with  fine  catgut,  and 
the  skin  with  silkworm-gut  or  horsehair.  If  the  line  of  suturing 
corresponds  with  the  seat  of  fracture,  drainage  should  be  secured 


f^'K-  305. — Proper  metliod  of  elevation  of  the  depression. 


through  a  small  opening  made  for  this  special  jnirpose  rather  than 
through  the  wound,  as  it  is  desirable  that  the  fragments  should  be 
covered  with  vascular  tissue.  According  to  the  size  of  the  wound 
and  the  length  of  time  it  was  exposed  to  infection  the  surgeon 
resorts  to  cither  tubular  drainage  or  capillary  drainage,  with  strips 
of  iodoform  gauze  or  a  small  bundle  of  catgut  or  horsehair.  Drain- 
age is  continued  until  the  woimd  has  been  shown  to  be  aseptic, 
or  has  been  made  so  by  vigorous  antiseptic  treatment. 


496  SPECIAL    FRACTURES. 

Comminuted  Compound  Fractures. — Open  comminuted  frac- 
tures of  the  skull,  inflicted  usually  by  a  blow,  a  kick,  or  a  fall, 
present  well-defined  conditions  for  prompt  and  thorough  surgical 
intervention.  These  injuries  frequently  involve  the  meninges  and 
the  brain  itself  The  scalp  wound  is  more  or  less  torn  or  contused, 
and  almost  always  infected  by  hair,  dirt,  and  other  foreign  sub- 
stances. Free  exposure  of  tlie  fracture  is  necessary  to  make  a  thor- 
ough search  for  foreign  infected  substances  and  to  determine  the 
extent  of  the  fracture  and  the  existence  and  nature  of  intracranial 
lesions.  If  necessary,  the  external  wound  is  enlarged  sufficiently 
to  expose  freely  the  comminuted  portion  of  the  skull.  Free  expo- 
sure of  the  fracture  is  also  an  essential  preliminary  step  to  the  primary 
disinfection  of  the  wojtnd.  Every  step  of  the  procedure  must  be 
done  under  strict  aseptic  precautions.  Before  the  wound  is  touched 
the  whole  scalp  and  the  surface  of  the  wound  are  disinfected.  Bone- 
cutting  instruments 
can  usually  be  dis- 
pensed with,  as  some 
of  the  fragments  are 
usually  found  loose, 
and  can  be  removed 
with  dissecting  or 
hemostatic  forceps. 
If  the  wound  is  a  re- 
cent one,  every  loose 
fragment  shoidd  be 
temporarily  removed 
and  placed  in  a  tvajin 
2^  per  cent,  solution 
of  carbolic  acid  for  dis- 
infection, during  the 
time  reqidred  i7t  dis- 
infecting the  wound.  Defects  of  the  skull  owing  to  such  injuries 
are  often  followed  by  serious  consequences,  and  must  be  carefully 
guarded  against  by  preserving  every  one  of  the  loose  fragments, 
removing  them  temporarily,  and  reimplanting  them  carefully  after 
the  wound  disinfection  has  been  completed.  The  temporary  re- 
moval of  detached  fragments  prepares  the  zvound  for  a  more  thorough 
disinfectioii. 

Depressed  fragments  are  elevated  with  the  utmost  care  to  pre- 
serve existing  vascular  connections,  contused  brain  tissue  is  excised, 
and  the  torn  dura  mater  is  sutured  with  fine  catgut  after  the  sub- 
dural hemorrhage  has  been  arrested.  Subdural  capillary  drainage 
IS  always  necessary  if  the  brain  has  been  exposed  by  the  injury.  In 
the  case  of  a  dural  defect  the  pericranium  from  the  adjacent  surface 
of  the  skull  should  be  utilized  in  the  form  of  a  flap  with  which  to 
cover  and  protect  the  surface  of  the  brain.  After  the  wound  has 
been  rendered  surgically  clean,  the  loose  fragments  are  transferred 


Fig.  306.— Comminuted  fracture  of  the  skull  (HofFa). 


COMMINUTED    COMPOUND    FRACTURES. 


497 


from  the  carbolized  solution  into  a  warm  physiologic  solution  of 
salt  prior  to  their  implantation  upon  the  surface  of  the  dura.  If 
the  fragments  are  large,  it  is  advisable  to  fragment  them  with  bone- 
cutting  forceps  and  reduce  them  to  the  size  of  the  thumb-nail  or 
smaller.  The  fragments  are  conveyed  from  the  salt  solution  to  the 
surface  of  the  dura  mater  with  dissecting  forceps,  and  are  planted 
in  such  a  manner  that  the  smooth  surface  comes  in  contact  with 
the  dura.  If  some  of  the  fragments  have  been  lost  by  the  injury, 
the  defect  can  be  filled  in  with  chips  of  bone  made  b}'  cutting  the 
remaining  fragments  through  the  diploe  separating  the  external 
from  the  internal 
table.  After  the 
mosaic  of  fragments 
has  been  completed, 
the  pericranium  and 
skin  are  sutured 
over  it,  so  as  to  se- 
cure for  the  bone 
chips  vascular  tis- 
sue on  both  sides. 
Drainage  must  be 
established  where  it 
is  most  needed,  pre- 
ferably through  a 
separate  opening  in 
the  scalp  some  dis- 
tance from  the  frag- 
ments. A  large 
h\'groscopic  sterile 
dressing,  held  in 
place  by  a  gauze 
roller  and  a  few 
turns  of  a  plaster-of- 
Paris  bandage,  com- 
pletes the  operation. 
If  the  woiaid  re- 
mains aseptic,  every 
one  of  the  fragments  will  retain  its  vitality  and  will  take  an  active 
part  in  the  restoration  of  the  continuity  of  the  skull. 

Should  the  wound  become  infected,  all  the  sutures  should  be 
removed,  the  wound  opened  widely,  and  all  the  loose  fragments  be 
removed  and  another  attempt  be  made  to  render  it  aseptic  by  re- 
sorting to  a  vigorous  secondary  disinfection  with  peroxid  of  hydro- 
gen, 2^2.  per  cent,  carbolic  acid  solution,  or  a  i  per  cent,  solution 
of  formalin.  Open  treatment  and  the  substitution  of  the  warm 
anti.septic  moist  compress  for  the  dry  dressing  constitute,  in  such 
an  event,  the  api)ropriate  after-treatment.  Even  in  such  cases 
nothing  has  been  lost  by  an  attempt  to  secure  restoration  of  the 
32 


Fig.  307. — Reimplantation  of  fragments  of  bone  in 
craniectomy  for  old  depressed  fractures  of  the  skull  and  in 
recent  fractures  when  the  wound  is  aseptic. 


498 


SPECIAL    FRACTURES. 


continuity  of  the  skull  by  the  preservation  of  detached  fragments, 
their  temporary  removal,  disinfection,  and  reimplantation. 

Punctured  and   Gunshot   Fractures. — Operative   treatment   is 
indicated  in  all   cases   of  punctured  and  gunshot  fractures  of  the 

skull.  These  injuries  are  almost  always 
complicated  by  visceral  wounds  of  the 
contents  of  the  skull,  and  the  vulnerat- 
ing  implement  or  bullet  often  carries  in- 
fected substances  with  it  into  the  interior 
of  the  skull.  The  opening  in  the  ex- 
ternal surface  of  the  skull  corresponds 
in  size  and  shape  to  the  weapon  or  mis- 
sile that  produced  the  fracture,  but  the 
internal  table  always  fractures  more  ex- 
tensively. Comminution  is  the  rule,  and 
the  fragments  often  are  driven  into  the 
substance  of  the  brain.  If  a  bullet  passes 
through  the  skull,  the  wound  of  exit  in 
the  skull  and  soft  tissues  is  larger  than 
the  wound  of  entrance,  as  when  the  bul- 
let penetrates  the  skull  from  within,  the  external  table  is  fractured 
more  extensively  than  the  internal,  the  conditions  being  the  reverse 
from  those  in  the  wound  of  entrance.  The  smaller  the  instrument 
with  which  a  punctured  wound  of  the  skull  is  inflicted,  the  greater 
the  probability  of  a  part  breaking  off  and  remaining  in  the  wound. 
Broken-off  knife-blades  have  repeatedly  been  overlooked,  and  have 


Fig.  308. — Mechanism  of 
gunshot  and  punctured  fractures 
of  the  skull. 


Fig.  309- — Removal  of  an  impacted  sword  point  with  chisel  and  hammer  (von  Esmarch 

and  Kowalzig). 

remained  impacted  in  the  skull  for  years,  until  discovered  at  post- 
mortems or  during  operations  for  cerebral  abscess.  The  point  of  a 
bayonet  has  been  found  so  firmly  fixed  in  the  perforation  that  it 
could  not  be  removed  without  the  aid  of  a  chisel.  In  every  punc- 
tured fracture  of  the  skull  it  becomes  necessary  to  ascertain  the 


PUNXTURED  AND  GUNSHOT  FRACTURES.  499 

kind  of  instrument  with  which  the  injury  was  inflicted,  and  to  ex- 
amine the  same  to  learn  whether  or  not  a  part  has  remained  m  the 
wound  The  perforation  in  the  skull  must  be  enlarged,  to  facilitate 
the  search  for  foreign  bodies,  and  to  enable  the  surgeon  to  grasp 
and  extract  the  detached  fragments  of  bone.  With  bone-cutting 
forceps  the  overhanging  external  table  is  removed,  until  the  open- 
ings in  the  external  and  internal  tables  of  the  skull  are  equal  in  size. 
Under  pedantic  aseptic  precautions  the  perforation  is  exposed  by 
enlarging  the  existing  opening,  or,  still  better,  by  reflecting  a  flap 
with  the*external  wound  in  its  center.  In  the  absence  of  a  foreign 
body  in  the  substance  of  the  brain,  digital  or  instrumental  explora- 
tion of  the  visceral  wound  should  be  abstained  from,  and  the  opera- 
tive treatment  limited  to  the  arrest  of  hemorrhage,  the  removal  of 
spicule  of  bone,  and  the  disinfection  of  the  extracranial  wound.  If 
foreign  substances  are  detected  in  the  intracranial  wound,  they  are 
removed  and  the  disinfection  is  extended  to  the  limits  of  the  part 
of  the  wound  exposed  to  infection.      Suturing  of  the  dura  and  im- 


Fjg.  -jio. — Keen's  rongeur  forceps  for  operations 


plantation  of  the  fragments  are  usually  impracticable  in  such  cases. 
Drainage  with  a  small  strip  of  iodoform  gauze  is  always  indicated 
and  should  be  continued  until  the  time  for  infection  has  passed. 

Gunshot  fractures  of  the  skull  should  invariably  be  subjected 
to  operative  treatment,  provided  this  holds  out  any  encouragement 
whatever  of  saving  life.  In  case  a  bullet  has  passed  through  the 
skull  and  its  contents,  the  entire  scalp  should  be  shaved  and 
thoroughly  disinfected.  The  wound  of  entrance  must  be  enlarged 
sufficiently  to  expose  the  perforation  freely,  which  is  then  enlarged 
with  chi.sel  and  de  Vilbiss  or  rongeur  forceps,  to  enable  the  surgeon 
to  remove  the  loose  spicuhe  of  bone  which  are  frequently  found 
at  some  distance  in  the  brain.  With  a  long,  eyed  probe  a  strip  of 
iodoform  gauze  large  enough  to  pack  the  tubular  visceral  wound 
loosely  should  be  inserted  from  the  wound  of  entrance  to  the 
wound  of  exit,  and  the  ends  of  the  drain  be  made  to  project  a  few 
inches  beyond  the  surface  of  each  wound.  Thorough  capillary 
drainage  of  this  kind  will  prevent  accumulation  of  primary  wound 


500 


SPECIAL    FRACTURES. 


Fig.  311. — De  Vilbiss  bone-cutting  forceps  for  operations 
on  the  skull. 


secretion  in  the  interior  of  the  skull,  and  will  be  of  value  in  arrest- 
ing capillary  hemorrhage.  A  large  hygroscopic  dressing,  envelop- 
ing the  entire  scalp  and  covering  both  wounds,  constitutes  the 
dressing,  and  must  be  held  in  place  by  a  few  turns  of  plaster-of- 

Paris  bandage.  The 
drain  must  be  allowed 
to  remain  until  the 
danger  of  infection  is 
passed,  when  it  is  re- 
moved gradually  by 
shortening  it  every 
day  or  two  on  the 
side  of  the  wound  of 
entrance,  because  in- 
fection is  more  likely 
to  take  place  here  than 
on  the  opposite  side. 
In  the  presence  of 
only  one  wound  in 
gunshot  fractures  of 
the  skull,  it  must  be  assumed  that  the  bullet  has  lodged  somewhere 
in  the  interior  of  the  skull.  Probing  of  a  brain  wound  in  the  ordinary 
manner  to  determine  the  location  of  the  bullet  is  a  practice  fraught 
with  danger,  and  yields  very  unsatisfactory,  and  often  misleading, 
diagnostic  information.  In  case  the  bullet  has  lodged  in  the  inte- 
rior of  the  skull,  the  wound  of  entrance  must  be  treated  in  the 
manner  described,  and  the  bullet  located  by  the  careful  use  of 
Fluhrer's  aluminum  probe.  The  head  is  placed  in  such  a  position 
that  the  tubular  wound  is  vertical,  when  the  gravitation  probe,  by 
its  own  weight,  finds  its  way  along  the  track  until  it  strikes  the  bullet 
or  the  opposite  side  of  the  skull,  in  case  the  bullet  has  become 
deflected  after  impinging 
upon  the  inner  surface  of 
the  skull,  as  happened  in 
the  famous  case  reported 
by  Fluhrer.  A  counter- 
opening  may  become  nec- 
essary in  order  to  remove 
the  bullet  if  it  has  reached 
the  opposite  side  of  the 
skull,  or  if  it  has  become 
deflected  or  arrested  near 
the  surface  of  the  brain, 
provided  the  locality  in  which  it  has  lodged  is  such  as  to  warrant 
operative  interference.  In  all  visceral  injuries  of  the  contents  of 
the  skull  resulting  from  gunshot  wounds,  capillary  or  tubular 
drainage,  or  a  combination  of  the  two,  is  indicated  and  should  be 
continued  until  there  is  no  further  danger  of  infection,  hemorrhage. 


Fig.   312. — Hopkins'   rongeur  forceps,  as  modified 
by  Weir,  for  operations  on  the  skull. 


PUNCTURED  AND  GUNSHOT  FRACTURES. 


501 


Fig-  3^3- — Skiagram  showing  part  of  the  bullet  inside  and  part  outside  of  the  skull, 
striking  the  skull  the  bullet  split  and  the  smaller  fragment  entered  the  skull. 


In 


Fig.  314. — Hullft  in  frciiital  lobe  of  brain  (lateral  view). 


^02  SPECIAL    FRACTURES. 

or  accumulation  of  wound  products,  when  the  drain  is  to  be  re- 
moved gradually.  Illumination  with  the  X-ray  has  finally  suc- 
ceeded in  locating  bullets  in  the  interior  of  the  skull,  as  can  be  seen 
from  the  skiagrams  (Figs.  313,  314,  and  315);  in  a  number  of 
cases  so  far  reported  it  furnished  the  principal  diagnostic  informa- 
tion that  enabled  the  surgeons  to  locate  and  remove  the  bullet. 


Fig-  S'^S- — Bullet  in  left  temporal  lobe  (lateral  illumination). 

Craniectomy  for  Hemorrhage  from  Middle  Meningeal  Artery. — 

The  middle  meningeal  is  one  of  the  largest  of  the  intracranial  arteries, 
and  when  cut  or  ruptured,  life  is  in  imminent  danger,  either  from 
loss  of  blood,  when  the  bleeding  vessel  is  exposed  by  an  external 
wound,  or  from  cerebral  compression  if  the  skull  is  intact  or  the 
extra vasated  blood  can  not  escape  through  the  fracture.  This 
artery  may  be  torn,  without  fracture  of  the  skull,  by  the  application 
of  blunt  force  sufficient  momentarily  to  change  the  contour  of  the 
skull  and  to  tear  the  vessel,  but,  owing  to  the  elasticity  of  the 
cranial  bones,  stopping  short  of  causing  a  fracture.  In  the  majority 
of  cases  the  vessel  injury  is  one  of  the  complications  of  a  fracture. 
In  either  case  the  artery  may  be  injured  at  a  point  opposite  to 
where  the  force  was  applied. 

Intracranial  hemorrhage  from  the  middle  meningeal  artery  gives 


CRANIECTOMY    FOR    HEMORRHAGE. 


503 


Fig.    316. — Hemorrhage    from    the   middle 
meningeal  artery  (Jacobson). 


rise   to  a   complexus   of    sj-mptoms    almost   characteristic  of   this 
injury.      In  the  absence  of  severe  concussion  or  brain  injury  the 
patient  is  often  able  to  walk  a  considerable  distance  before  symptoms 
of  compression    set    in.      The 
hemiplegia    on    the     opposite 
side  develops  gradually.      The 
progressive  increase  in  the  in- 
tensitx-  of  the  focal  symptoms 
distinguishes  this   injury  from 
the  symptoms  caused  by  a  de- 
pressed fracture  or  visceral  in- 
jury of  the  brain.     After  the 
hemiplegia    is    complete,    loss 
of     consciousness,     stertorous 
breathing,     dilatation     of     the 
pupils,  and  other  indications  of 
more  diffuse  cerebral  compres- 
sion    make    their    appearance, 
and,    unless    prompt    surgical 

intervention  is  instituted,  death  from  acute  cerebral  compression  is 
the  rule.  There  are,  however,  exceptions  to  this  rule.  I  have 
seen  a  case  of  hemorrhage  from  the  middle  meningeal  artery,  com- 
plicating a  fracture 
at  the  base  of  the 
skull,  eventually  re- 
cover completely 
without  operative 
treatment.  The  pa- 
tient was  uncon- 
scious for  a  number 
of  days  and  com- 
pletely hemiplegic. 
The  paralysis  grad- 
ually disappeared  in 
the  course  of  six 
months.  Such  cases 
are,  however,  ex- 
ceptional, and  do 
not  disqualify  the 
rule  previously  laid 
down  that  hemor- 
rhage from  the  mid- 
dle meningeal  artery 
furnishes  a  positive 
indication  for  the 
employment  of  direct  hemostatic  measures.  If  the  dura  is  intact, 
the  extravasation  will  be  foiuid  between  it  and  the  inner  siuface  of 
the  cranial  bones;    if  the   dura  is  ruptured,  the  hematoma  may  be 


Fig.  317. — .Site  of  tre])hine  opening  to  reach  clot  in 
hemorrhage  from  middle  meningeal  artery  (Kronlein)  : 
n-b.  Horizontal  line  through  the  meatus;  c-d,  on  a  line 
with  the  eyebrf)ws  ;  e-f,  vertical  line,  from  three  to  four 
centimeters  behind  the  external  angular  process;  g-h,  at 
the  [josterior  border  of  the  mastoid  ])rocess  ;  A,  the  point 
to  reach  the  anterior  branch,  and  15,  that  to  reach  the 
posterior  branch  (von  Esmarch  and  K(iwalzig). 


504 


SPECIAL    FRACTURES. 


almost  entirely  subdural,  or  if  the  tear  in  the  dura  is  limited  and 
opposite  the  bleeding  point,  subdural  and  epidural.  The  location 
of  the  blood-clot  will  depend  on  the  part  of  the  vessel  injured  : 
most  frequently  it  is  found  in  the  temporoparietal  region,  next  in 
frequency  in  the  parieto-occipital  region,  and  least  frequently  in  the 
frontotemporal  region,  according  as  the  main  artery  or  the  posterior 
or  anterior  branches  are  torn.  If  the  fracture  of  the  skull  corre- 
sponds with  the  arterial  wound,  the  bleeding  vessel  is  exposed  by 
the  temporary  removal  of  the  fragments,  and  if  the  bleeding  point 
is  not  made  sufficiently  accessible,  the  opening  is  enlarged  with  the 
rongeur  or  de  Vilbiss  forceps.      Direct  ligation  is  seldom  possible. 

The  best  course  to 
pursue  is  to  pass  a 
catgut  ligature  with 
a  well-curved,  round 
needle  underneath 
the  vessel,  including 
some  of  the  dural 
tissue,  and  tie  care- 
fully. If  the  artery 
is  in  a  complete  bony 
canal,  as  is  occasion- 
ally the  case,  the 
ligature  is  useless, 
and  hemorrhage 
must  be  arrested  by 
crushing  the  bone  at 
the  bleeding  point 
with  a  sequestrum 
forceps,  or  by  spiking 
the  canal  with  an 
aseptic  ivory  nail. 
Such  a  spike  can  be 
extemporized  with  a 
file  from  an  ordinary 
crochet-needle.  Boil- 
ing for  from  ten  to 
fifteen  minutes  in  a  soda  solution  will  sterilize  the  nail.  In  emer- 
gency cases  a  sterilized  toothpick  will  answer  a  useful  purpose  ; 
this  has,  however,  this  great  disadvantage,  that  the  wooden  spike 
must  be  removed  at  the  end  of  from  forty-eight  to  seventy-two 
hours. 

As  the  free  hemorrhage  usually  obscures  the  field  of  operation, 
digital  compression  of  one  or  both  carotid  arteries  recommends 
Itself  as  a  useful  temporary  hemostatic  resource  until  the  bleeding 
vessel  has  been  found  and  tied.  If  the  bleeding  point  can  not  be 
reached  from  the  seat  of  fracture,  or  if  the  skull  is  not  fractured, 
the  main  artery  must  be  exposed  and  ligated  in  the  temporal  fossa! 


Fig-  318. — Osteoplastic  resection  of  the  skull  for  ligation 
of  the  middle  meningeal  artery. 


COMPOUND    FRACTURES.  505 

This  can  be  done  with  the  greatest  safety  and  with  the  best  pros- 
pects of  finding  the  vessel  by  making  an  osteoplastic  resection. 
The  flap  should  be  at  least  one  and  one-half  or  two  inches  wide  and 
three  inches  in  length,  with  the  base  above  the  z}^gomatic  arch. 
The  convex  border  of  the  flap  should  correspond  with  the  temporal 
ridge.  The  flap  includes  the  skin,  temporal  fascia,  muscle,  perios- 
teum, and  bone.  The  operator  must  remember,  in  using  the  chisel, 
that  the  bone  in  this  locality  is  very  thin.  After  outlining  the  piece 
of  bone  to  be  elevated  by  a  groove  made  with  gouge  and  hammer, 
the  internal  table  is  fractured  with  a  narrow,  thick  chisel  ground  on 
one  side.  The  fracture  at  the  base  of  the  flap  can  be  made,  without 
much  cross-cutting,  by  the  use  of  the  elevator.  On  reflecting  the 
flap  the  main  artery  and  the  anterior  and  posterior  branches  are 
exposed,  and  if  the  bleeding  point  is  not  found,  the  main  artery  is 
tied.  By  opening  the  skull  in  the  manner  indicated  the  hematoma 
comes  within  reach  and  is  removed  before  or  after  the  artery  is  tied. 
After  complete  hemostasis  and  removal  of  the  extravasation,  the 
flap  is  sutured  in  place  without  making  provision  for  drainage. 
Should  hemostasis  not  be  complete,  drainage  is  established  by 
making  a  buttonhole  in  the  base  of  the  flap,  and  by  cutting  away 
a  small  semicircular  piece  from  the  fractured  surface  of  the  tem- 
porarily displaced  bone,  and  by  inserting  a  tubular  or  gauze  drain, 
or  by  combining  tubular  and  capillary  drainage. 


CHAPTER  XI. 

COMPOUND  FRACTURES. 

Compound  fractures  belong  to  the  gravest  class  of  injuries  that 
come  under  the  care  of  the  general  practitioner.  The  responsi- 
bility of  those  who  render  the  first  aid  in  such  accidents  is  very 
great,  as  upon  prompt  and  intelligent  action  depend  the  preserva- 
tion and  future  usefulness  of  the  fractured  limb,  and  often  the  life 
of  the  patient.  The  danger  to  limb  and  life  in  such  cases  consists 
usually  in  the  presence  of  the  wound  in,  and  the  extent  of  injury  to, 
the  soft  parts,  rather  than  in  the  fracture  itself.  A  subcutaneous 
fracture  with  extensive  comminution  under  appropriate  treatment 
usually  heals  in  a  satisfactory  manner,  while  a  much  less  extensive 
fracture,  complicated  by  a  communicating  wound  with  the  surface, 
places  the  limb  and  life  of  the  patient  in  jeopardy  in  case  the  wound 
becomes  infected.  The  treatment  of  compound  fractures  must 
meet  many  and  more  difficult  indications  than  that  of  simple  frac- 
tures. The  complications  that  arc  frequently  met  in  such  injuries 
often  make  it  difficult  to  decide  whether  the  conditions  are  such  as 
to  warrant  con.servative  treatment  or  whether  primary  amputation 


5o6  COMPOUND    FRACTURES. 

should  be  performed.  If  a  conservative  plan  of  treatment  is  de- 
cided upon,  the  prognosis  in  reference  to  the  danger  to  Hfe  and  as 
to  securing  a  useful  limb  is  influenced  unfavorably  by  the  existing 
wound. 

The  term  compound  originated  in  England,  and  is  used  to  dis- 
tinguish open  from  simple  or  subcutaneous  fractures.  The  English 
and  American  surgeons  understand  a  compound  fracture  to  be  one 
in  which  a  communication  between  the  medullary  tissue  at  the  seat 
of  fracture,  a  tissue  extremely  susceptible  to  pyogenic  infection 
and  the  external  air,  is  established  through  a  wound  of  the  soft 
parts.  A  complicating  wound  that  does  not  communicate  with  the 
seat  of  fracture  does  not  add  materially  to  the  danger  of  the  in- 
jury, nor  does  it  interfere  with  a  satisfactory  process  of  repair  of 
the  fractured  bone.  The  great  risk  of  a  compound  fracture  is 
infection  of  the  exposed  medullary  tissue,  with  its  immediate  and 
remote  consequences.  The  German  and  French  surgeons  include 
compound  fractures  under  the  head  of  complicated  fractures,  a 
term  restricted  in  this  country  and  in  England  to  designate  fractures 
complicated  by  injuries  of  the  soft  parts  that  are  important  in  main- 
taining the  nutrition  of  the  limb,  such  as  wounds  of  large  blood- 
vessels and  nerves.  The  classification  into  open  and  closed  frac- 
tures, as  has  been  recently  proposed,  would  probably  accomplish 
much  in  doing  away  with  the  prevailing  confusion  regarding  what 
is  meant  by  a  compound  fracture,  but  it  requires  time  to  make  the 
change  a  general  and  permanent  one  in  the  countries  where  the 
profession  has  been  brought  up  and  educated  in  the  term  com- 
pound as  applied  to  fractures. 

In  the  discussion  of  compound  fractures  the  remarks  will  apply 
exclusively  to  fractures  of  the  long  bones.  The  distinction  between 
open  and  closed  fractures  is  an  important  one,  from  a  prognostic  as 
well  as  a  therapeutic  standpoint,  even  at  the  present  time,  when  the 
surgeon's  efforts  at  preventing  wound  infection  are  more  successful 
than  they  were  a  quarter  of  a  century  ago.  The  high  degree  of 
receptivity  of  the  medullary  tissue  to  pyogenic  infection  is  well 
known  and  fully  realized.  Before  antiseptic  surgery  was  known, 
suppurative  osteomyelitis  followed  nearly  every  amputation  and 
seldom  was  delayed  for  more  than  ten  days  in  compound  fractures. 
The  old  museums  of  pathologic  anatomy  are  overstocked  with 
sequestra  of  all  sizes  and  shapes,  obtained  from  patients  after  a 
hard  struggle  for  life  or  more  frequently  from  the  postmortem 
room.  The  innumerable  deaths  from  pyemia  in  both  classes  of 
patients  were  caused,  with  few  exceptions,  by  osteomyelitis.  All 
wounds  complicating  fractures  must  be  regarded  as  infected  wounds, 
and,  as  can  be  seen  from  the  recent  statistics,  the  most  painstaking 
surgeon,  in  a  well-equipped  hospital,  is  not  always  able  to  guard 
against  infection  by  the  most  energetic  recourse  to  antiseptic  pre- 
cautions. Antiseptic  surgery  has  accomplished  much  in  eliminat- 
ing the  dangers  incident  to  wound  infection,  but  we  can  not  claim 


OLD    STATISTICS.  50/ 

for  it  absolute  protection.  The  cases  often  come  to  the  surgeon 
after  the  infection  has  gained  a  firm  foothold,  and  the  most  thorough 
and  energetic  antiseptic  measures  are  usually  powerless  in  arresting 
the  extension  of  the  infection  before  great  damage  has  been  inflicted 
upon  the  fractured  bone  and  the  adjacent  soft  tissues. 

Old  Statistics. — The  value  of  timely  antiseptic  treatment  of  the 
wound  complicating  compound  fractures  is  made  most  apparent  by 
comparing  the  old  with  recent  statistics.  What  the  mortality  of 
compound  fractures  was  before  statistics  were  available  may  readily 
be  imagined.  Few  escaped  with  their  lives  before  surgeons  knew 
how  to  immobilize  a  compound  fracture  proper!}'.  Considerable 
gain  was  made  in  the  treatment  of  compound  fractures  after  sur- 
geons realized  the  importance  of  proper  immobilization  of  the  injured 
limb,  but  they  were  almost  powerless  in  preventing  wound  infection 
until  Lister  announced  his  great  discovery.  Before  antiseptic  sur- 
gery was  practised  in  Germany  nearly  50  per  cent,  of  all  cases  of 
compound  fractures  died  from  hospital  gangrene,  sepsis,  erysipelas, 
or  pyemia,  and  primary  amputation  had  little  influence  in  diminish- 
ing this  enormous  mortality.  Volkmann  publicly  stated  that  in  his 
own  practice  and  in  that  of  his  predecessors  the  mortality  of  com- 
pound fractures  in  the  Halle  Clinic  before  the  antiseptic  treatment 
was  introduced  was  40  per  cent.  Of  the  last  twelve  cases  of  com- 
pound fracture  of  the  leg  that  were  treated  on  the  old  plan  and 
that  came  under  his  own  observation,  every  one  died  of  pyemia 
or  septicemia.  Volkmann  and  Frankel  collected  388  cases  of  com- 
pound fracture  of  the  leg  from  civil  practice,  treated  conservatively 
under  the  old  method,  with  a  mortality  of  32.5  per  cent. 

From  England  comes  the  report  of  Thomas  Bryant,  giving  the 
results  of  treatment  of  302  compound  fractures  treated  in  Guy's 
Hospital  during  twenty  years  previous  to  the  introduction  of  anti- 
sepsis. Of  this  number,  177  were  treated  on  the  conservative  plan, 
and  of  these,  39  died.  In  91  cases  primary  amputation  was  per- 
formed, and  of  these,  57  died.  Secondary  amputation  became  neces- 
sary in  31  cases,  and  of  these,  19  died.  In  all  cases  in  which  the 
fracture  implicated  any  of  the  large  joints  the  result  was  uniformly 
fatal.  Similar  experiences  prevailed  in  France.  Despres  treated, 
during  the  year  1872-73,  13  cases  of  compound  fracture  of  the  leg 
by  applying  camphor  wine  to  the  wound  and  by  immobilizing  the 
limb  in  a  fracture  box.  Eight  of  these  were  treated  throughout  on 
a  conservative  plan,  and  of  these,  6  died  ;  of  5  treated  by  amputa- 
tion, 4  died,  so  that  of  the  whole  number,  13,  of  compound  fractures 
of  the  leg,  only  3  recovered.  The  following  year  he  treated  1 1 
ca.ses  by  protecting  the  wound  with  diachylon  plaster  and  by  immo- 
bilization of  the  limb  in  a  plaster-of-Paris  dressing,  with  the  result 
that  only  one  died,  a  difference  in  the  mortality  that  he  attributed 
to  more  perfect  immobilization  of  the  limb.  During  the  Franco- 
Prussian  war  he  .saw,  at  Sedan,  8  gunshot  fractures  of  the  leg,  of 
which  3  died  ;  at  Beaugcncy  26,  of  which  7  died.      He  believed 


5o8  COMPOUND    FRACTURES, 

that  the  comparatively  low  mortality  in  military  as  compared  with 
civil  practice  in  such  cases  was  due  to  the  fact  that  the  bullet  usu- 
ally passed  through  the  limb,  leaving  two  openings  for  free  drainage. 

We  can  not  show  much  better  results  in  our  own  country  in  the 
treatment  of  compound  fractures  under  the  old  regime.  Of  i66 
compound  fractures  of  the  large  long  bones  treated  in  the  Pennsyl- 
vania Hospital  from  January  i,  1839,  to  April  i,  1857,  reported  by 
Norris,  71  died.  Of  30  cases  treated  by  amputation,  20  died. 
During  the  same  period  of  time  158  compound  fractures  were 
treated  in  the  New  York  Hospital,  with  a  mortality  of  50  per  cent, 
as  reported  by  Lente.  The  fearful  mortality  that  attended  gunshot 
fractures  of  the  extremities  during  the  Civil  War  lives  in  the  memory 
of  many  surgeons  who  are  actively  engaged  in  professional  work  at 
the  present  time.  This  mournful  picture  of  suffering,  mutilation, 
and  death  caused  by  compound  fractures  under  the  old  treatment, 
as  shown  by  the  foregoing  statistics,  is  only  a  partial  portrayal  of 
the  actual  results,  as  they  comprise  cases  from  the  practice  of  experi- 
enced surgeons,  and  do  not  include  the  enormous  material  in  the 
hands  of  general  practitioners.  Let  us  turn  away  from  the  sicken- 
ing details,  and  in  the  light  of  modern  surgery  consider  the  treat- 
ment of  compound  fractures  as  reflected  by  recent  statistics. 

Recent  Statistics. — Volkmann  did  more  to  develop  and  per- 
fect the  modern  treatment  of  compound  fractures  than  any  other 
surgeon.  In  his  classic  address,  delivered  before  the  International 
Medical  Congress,  London,  1881,  on  "  Modern  Surgery,"  he  refers 
to  the  radical  changes  that  have  taken  place  in  the  treatment  of 
compound  fractures  and  its  results  since  the  antiseptic  treatment 
has  been  generally  adopted.  After  giving  his  experience  with  the 
old  treatment,  he  made  the  statement  that  of  the  first  135  cases 
treated  antiseptically  in  his  clinic  he  lost  only  two,  one  of  fat 
embolism,  and  the  other,  a  potator,  of  delirium  tremens.  In  1886 
Bruns  tabulated  254  cases  of  compound  fracture,  treated  with  car- 
bolized  preparations,  from  the  practice  of  leading  German  surgeons, 
distributed  as  follows  : 

75  cases,  Volkmann,    1873-77.  38  cases,  Wilms,    1877-78. 

60  cases,  Bardeleben,  1875-78.  28  cases,  Schede,  1875-77. 

53  cases,  Socin,  1873-79. 

Of  this  number,  84  involved  the  upper  extremity,  45  were  frac- 
tures of  the  shaft,  30  were  joint  fractures,  and  9  were  complicated 
cases.  The  lower  extremity  is  represented  by  170  cases,  among 
them  132  of  the  shaft,  35  joint  fractures,  and  3  complicated  cases. 
The  total  mortality  amounted  to  9  per  cent.  Of  the  23  fatal  cases, 
I  died  of  collapse,  i  of  fat  embolism  and  hemorrhage,  7  of  delirium 
tremens,  2  of  tetanus,  4  of  pyemia,  and  7  of  septicemia.  The  mor- 
tality due  to  septicopyemia  is,  therefore,  reduced  to  4.3  per  cent., 
and  in  many  of  the  fatal  cases  from  this  cause  infection  was  present 
at  the  time  the  patients  came  under  treatment,  so  that  the  real  mor- 
tality from  sepsis  is  reduced  to  3.5   per  cent.      Of  the  84  cases  of 


RECENT    STATISTICS.  5^9 

fracture  of  the  upper  extremity  that  came  under  treatment  Avithin 
twentv-four  hours,  2  died,  i  of  septicemia,  and  of  lO  who  came 
under  treatment  after  the  expiration  of  twenty-four  hours,  2  died, 
only  I  of  septicemia.  Of  the  170  open  fractures  of  the  lower 
extremity  141  came  under  treatment  during  the  first  twenty-four 
hours-  of  these,  13  died  of  septicopyemia;  of  the  29  that  came 
under  'treatment  later,  6  died— 5  of  septicopyemia.  Of  the  cases 
that  came  under  treatment  during  the  first  twenty-hours,  m  1 1 5 
aseptic  healing  of  the  wound  occurred.  In  the  cases  m  which  the 
first  aid  was  rendered  later,  the  mortality  from  sepsis  was  three 
times  crreater,  and  the  number  of  aseptic  wound  healings  was  re- 
duced 1)ne-half.  In  168  compound  fractures  of  the  shaft  of  the 
lono-  bones  the  fracture  failed  to  unite  in  5.  and  in  12  cases  bony 
uniSn  was  delayed— over  ten  weeks.  Of  the  48  cases  in  which 
lar^e  joints  were  involved,  32  were  treated  upon  a  conservative 
plan  (1  died  of  tetanus)  ;  in  8  primary  resection  was  done  ;  m  2,  sec- 
ondary resections  ;  and  in  6  secondar>'  amputation  became  neces- 
sary The  mortality  from  accidental  wound  infection  amounts  to 
6  ->  per  cent.  ;  from  sepsis,  4.  i  per  cent.  In  3 1  cases  a  good  func- 
tional result  was  obtained,  and  only  in  3  did  ankylosis  occur. 

\\'61fler  has  recently  published  his  experience  in  the  treatment 
of  compound  fractures'  in  his  clinic  at  Graz.  Nineteen  were  ad- 
mitted in  a  septic  condition  ;  of  the  remaining  88,  2  died  of  tetanus, 
and  I,  a  case  of  extensive  crushing  of  the  thigh  in  which  amputa- 
tion was  objected  to,  succumbed  to  sepsis.  He  makes  use  of  the 
term  "  atoxis  "  to  describe  the  procedure  necessary  to  convert  an 
infected  into  an  aseptic  wound.  M.  Villars  has  reported  another 
series  of  compound  fractures  from  the  Halle  Clinic  since  the  publi- 
cation of  Volkmann's  paper  on  the  same  subject.  The  absolute 
mortality  was  7.7  per  cent.,  including  deaths  from  sepsis  present  at 
the  time  the  patients  were  admitted  and  complications  occurring 
independently  of  the  fracture.  Of  the  90  cases,  60  recovered  with 
useful  limbs  and  excellent  union  of  the  fracture.  In  6  cases  ampu- 
tation, and  in  3  exarticulation,  became  necessary  to  save  life.  The 
treatment,  on  the  whole,  was  of  the  most  conservative  nature.  The 
wound  was  seldom  sutured,  but  direct  fixation  of  the  fragments  by 
suturing  was  frequently  practised.  In  delayed  union  callus  forma- 
tion was  stimulated  by  steel  or  ivory  nails  driven  into  the  ends  of 
the  bone,  and  circulation  was  increased  by  permitting  the  patients 
to  use  the  limb,  properly  immobilized,  before  union  by  bony  callus 
was  complete. 

In  a  valuable  article  Mumford  gives  the  results  of  treatment  of 
300  cases  of  compound  fracture  in  the  Massachusetts  General- 
Hospital  during  eight  yeans— from  1887  to  1895.  He  excludes 
from  the  list  those  cases  that  died  within  the  first  twelve  hours  and 
those  treated  by  primary  amputation.  Of  the  300  cases,  30  died— 
a  mortality  of  10  per  cent.  ;  the  causes  of  death  were  :  Sepsis,  10  ; 
shock,  7  ;  delirium  tremens,  6  ;  fat  embolism,  3  ;  gangrene,  3  ;  acute 


5IO 


COMPOUND    FRACTURES. 


nephritis,  i.  In  171  cases  the  fracture  was  of  one  or  both  bones 
of  the  leg,  with  18  deaths — a  Httle  more  than  10  per  cent.  ;  the 
highest  mortahty  was  in  fractures  of  the  femur — 25  cases  with  7 
deaths — 28  per  cent.  In  50  cases  involving  joints  there  were  only 
3  deaths.  In  20  cases  secondary  amputation  was  performed.  Pri- 
mary wiring  of  the  fragments  was  done  27  times,  and  in  7  of  the 
cases  necrosis  followed.  These  recent  statistics  show  conclusively 
what  antiseptic  surgery  has  done  for  the  treatment  of  compound 
fractures.  For  reasons  that  are  not  difficult  to  comprehend  it  has 
not  succeeded,  and  probably  never  will  succeed,  in  reducing  the  mor- 
tality from  septic  complications  to  nil,  but  it  has  already  reduced 
it  from  over  50  per  cent,  to  an  average  of  not  much  over  5  per 
cent.  While  it  has  done  so  much  in  the  way  of  saving  life,  it  has 
perhaps  done  more  in  the  prevention  of  mutilating  operations, — 
primary  and  secondary  amputations  and  resections, — in  shortening 
the  healing  process,  and  in  improving  and  increasing  the  functional 
results.  Under  the  old  treatment  primary  healing  of  the  wound 
was  the  exception,  even  in  the  simplest  cases.  In  the  cases  that 
recovered  from  the  septic  complications  the  fracture  ultimately 
healed  after  a  long  siege  of  suppuration,  and  often  extensive  seques- 
tration, following  the  traumatic  suppurative  osteomyelitis,  accidents 
that  could  not  fail  greatly  to  retard  recovery  and  to  impair  the 
functional  results. 

Compound  fractures  have  lost  their  fornier  bad  reputation  solely 
on  account  of  the  improved  methods  of  dealing  with  the  external 
wound  since  the  introduction  of  antiseptic  surgery  by  Lister. 
Under  strict  antiseptic  precautions,  timely  employed,  the  majority 
of  compound  fractures  heal  in  the  same  manner  as  simple  fractures, 
in  the  same  length  of  time,  and  with  no  more  suffering  and  equally 
as  satisfactory  functional  results.  Formerly  the  surgeons  who  had 
become  painfully  aware  of  the  great  dangers  arising  from  inflamma- 
tion aimed  to  prevent  and  combat  it  by  the  employment  of  ener- 
getic antiphlogistics, — application  of  cold,  restricted  diet,  venesec- 
tion sedatives,  emetics,  and  cathartics^ — while  the  modern  surgeon, 
on  the  other  hand,  scores  such  marvelous  results  by  excluding  or 
rendering  harmless  the  direct  cause  of  infection  and  by  husbanding 
the  strength  and  recuperative  energies  of  the  patient.  Subcutaneous 
fractures  suppurate  only  in  exceptional  cases,  even  when  the  bone 
is  extensively  splintered  and  the  soft  tissues  are  seriously  injured. 
Lister,  following  Pasteur's  researches,  showed  that  it  was  not  the 
atmospheric  air,  as  was  formerly  believed,  but  the  micro-organisms 
suspended  in  it,  that  produced  the  fermentative  and  putrefactive 
processes  in  the  primary  wound  secretions.  It  is  the  antiseptic 
treatment  of  the  wound  that  must  be  credited  with  having  wrought 
so  radical  a  change  in  the  results  of  the  modern  treatment  of  com- 
pound fractures,  and  it  is  the  surgeon  who  is  perfectly  familiar  with 
the  principles  and  practice  of  antisepsis  who  will  be  most  success- 
ful in  the  management  of  such  cases. 


ETIOLOGY.  5 


Etioloev  -The  manner  in  which  a  compound  fracture  is  pro- 
'"'°c\rSt  in -ch  cases  is  usually  slight  or  entirely  absent. 


F,„    „0  -Perforating  frac.ure  of  the  humerus;  upper  sharp  fr.Bmeut  thrust  through 
F,g.  319.     *^'="''["  Ji„_  „hich  firmly  embraces  the  protruding  bone. 

The  fratrment  or  fragments  that  perforated  the  skin  may  be  found 
^rotrudn"  by  the  su'geon  when  the  case  comes  under  h^.ohscr^- 
Son   nivhich  event  the  wound,  to  a  certain  extent  ,s  l"ot^<^'fk>' 
Tsho  t  time  against  i.ifection  by  the  mechanical  barrte,"  furntshed 
b;  thl  dis;iac 'd  fragment.     These  are  the  most  av-b  e  ---,- 
f/r  IS  the  Dievention  of  infection  is  concerned.      In  othci  cases  ine 
proiec  in/f  agment  is  replaced  spontaneously  or  by  the  intervention 
^    ncrsons  who  are  first  brought  in  contact  w.th  the  pattent.       n 
cr^nimnces  the  danger  of  inaction  is  greater  as  the  ^rojecttng 
part  of  the  bone  may  have  become  ,n  ected  ^^""«^"°^^  ^l 
.  WIS  extruded   or  pathogenic  micr.jbes  from  other  sources  n  ly 
have  ent'^ed  tfl;  wound  cavity  through  the  perforation  before  the 


512 


COMPOUND    FRACTURES. 


patient  comes  under  the  care  of  the  surgeon.  A  simple  fracture 
may  be  made  compound  if  the  patient,  after  the  accident  has  oc- 
curred, makes  an  attempt  to  use  the  Hmb.  This  was  the  case  with 
Mr.  Pott,  who  sustained  a  fracture  that  bears  his  name.  A  similar 
complication  may  occur  in  the  subjects  of  simple  fracture  who  later 
become  afflicted  with  delirium  of  any  kind.     A  simple  fracture   is 

occasionally  made  compound 
by  decubitus  from  without  or 
within,  by  splint  pressure  or 
great  displacement  of  the  frag- 
ments, and  in  rare  instances  by 
the  occurrence  of  suppuration 
at  the  seat  of  a  simple  fracture. 
As  instances  of  compound 
fractures  resulting  from  direct 
violence  maybe  mentioned  gun- 
shot fractures  and  those  from 
kicks,  blows,  and  the  passage 
of  the  wheels  of  a  heavy  vehicle 
of  any  kind.  The  last  method 
of  causing  a  compound  fracture 
produces  injuries  of  the  gravest 
kind  by  inflicting  extensive 
comminution  of  bone  and  seri- 
ous crushing  of  important  soft 
tissues.  The  degree  of  com- 
minution caused  by  bullet  in- 
juries depends  largely  on  the 
range  from  which  the  missile 
was  fired.  The  modern  small- 
caliber  bullet  causes  extensive 
comminution  within  a  distance 
of  500  yards  ;  it  drills  the  bone 
the  next  500  yards ;  and  be- 
yond that  range  more  or  less 
comminution  again  takes  place. 
Loss  of  bone  tissue  is  some- 
times sustained  in  perforating 
fractures  by  the  breaking-ofif  of 
the  projecting  piece  of  bone 
under  the  influence  of  the  same  force  that  produced  the  com- 
pound fracture.  In  other  cases  the  crushing  is  so  extensive  and 
the  external  wound  so  large  that  some  of  the  fragments  are  lost 
before  the  patient  receives  surgical  attention.  The  lower  ex- 
tremities are  more  frequently  the  seat  of  compound  fracture 
than  the  upper.  According  to  Gurlt,  the  most  reliable  authority, 
19.91  per  cent,  of  all  fractures  are  compound.  In  fractures 
of  both    bones  of  the    leg    17.96    per    cent,    are  compound.      In 


Fig.  320. — Compound  comminuted  fracture 
of  the  tibia  from  the  kick  of  a  horse. 


DIAGNOSIS.  5  I  3 

fractures  of  both  bones  of  the  forearm  11.68  per  cent,  are  com- 
pound; of  shaft  of  the  femur,  7.05  per  cent.  ;  of  the  humerus,  6  66 
per  cent.  The  greater  frequency  with  which  fractures  of  the  leg 
are  compound  than  are  those  of  the  forearm  is  undoubtedly  due 
to  the  fact  that  more  simple  fractures  of  the  leg  are  made  com- 
pound by  continuation  of  the  same  force  that  produced  the  sim- 
ple fracture,  or  by  bending  at  the  seat  of  fracture  under  the  weight 
of  the  body,  or  on   attempts   to    use   the   limb   after   the  fracture 

has  occurred. 

Diagnosis. — The  diagnosis  in  the  majority  of  cases  ot  com- 
pound fractures  presents  no  special  difficulties.  If  the  fractured 
bones  are  exposed,  or  if  the  wound  is  large  and  the  fragments  are 
readily  accessible,  a  glance  or  a  touch  settles  the  existence  of  a 
fracture  and  the  presence  of  a  complicating  wound.  In  more 
doubtful  cases  no  digital  or  instrumental  examination  is  justifiable  in 
efforts  to  establish  the  compound  nature  of  the  fracture,  except  imder 
strict  aseptic  precautions.  It  is  in  such  cases  that  meddlesome 
exploration,  digital  or  instrumental,  does  great  harm,  because  quite 
frequently  a  very  thin  layer  of  soft  tissue  covers  the  fragments  ; 
this  thin  bassin  du  infection,  when  torn,  establishes  an  infection 
atrium  communicating  with  the  seat  of  fracture.  As  a  rule,  digital 
exploration  should  not  be  encouraged  except  it  be  done  under 
strict  aseptic  precautions.  The  external  wound  and  its  environment 
should  be  thoroughly  disinfected,  and  the  examination  made  with  a 
finger  faultlessly  aseptic.  A  wide  experience  has  demonstrated  the 
danger  of  exploring  gunshot  wounds  with  -the  probe,  and  this 
instrument  has,  for  good  reasons,  become  almost  obsolete  in  the 
examination  of  recent  gunshot  fractures.  If,  after  a  careful  examina- 
tion, any  doubt  remains  as  to  the  compound  nature  of  the  fracture, 
the  patient  must  be  given  the  benefit  of  the  same,  and  the  case 
must  be  treated  on  principles  appropriate  to  the  doubt  entertained. 
By  following   such  a  course    nothing  is  lost   and   much   may  be 

gained. 

The  diagnosis  in  compound  fractures  has,  however,  more  in 
view  than  the  .settlement  of  the  existence  of  a  wound  communicating, 
on  the  one  hand,  with  the  surface,  and,  on  the  other,  with  the  seat 
of  fracture.  It  is  important  to  ascertain  the  extent  of  communica- 
tion and  the  location  and  degree  of  displacement  of  the  fragments. 
This  can  be  done  only  by  making  a  careful  inspection  and  digital 
exploration  of  the  wound.  It  is  equally  necessary  to  ascertain  the 
existence  and  nature  of  additional  complications.  This  part  of  the 
examination  has  special  reference  to  the  extent  of  injury  to  the  soft 
parts,  skin,  muscles,  vessels,  and  nerves.  Imperfect  or  superficial 
attention  given  to  this  part  of  the  examination  has  often  resulted  in 
.serious  harm  to  the  patient  and  in  unnecessary  damage  to  the 
reputation  of  the  attendant.  Crushing  injuries  are  peculiarly  de- 
ceptive in  this  re.spect.  The  apparently  slight  injury  of  the  skm 
over  the  crushed  hone,  and  the  soft  tissues  interposed  between 
33 


514  COMPOUND    FRACTURES. 

them,  has  often  given  rise  to  serious  mistakes  in  prognosis  and 
treatment.  The  great  elasticity  of  the  skin  often  permits  extensive 
comminution  of  bone  and  crushing  of  the  soft  tissues — conditions 
Hable  to  be  overlooked  unless  the  examination  is  conducted  with 
the  necessary  degree  of  care  and  thoroughness.  Injury  of  the 
intima  of  large  blood-vessels  from  crushing  or  traction  force  is  not 
infrequently  present  in  such  cases,  and  is  manifested  clinically  soon 
after  the  injury  has  been  received,  not  by  a  complete,  but  by  a 
partial,  interruption  of  the  peripheral  circulation.  The  circulation 
may  also  be  threatened  from  compression  of  the  principal  blood- 
vessels, arteries,  and  veins,  caused  by  one  or  more  displaced  frag- 
ments. The  condition  of  the  peripheral  circulation  should  be 
studied  with  the  utmost  care,  for  the  purpose  of  ascertaining  the 
existence  or  absence  of  obstructive  traumatic  lesions  from  intra- 
vascular or  extravascular  causes.  The  condition  of  innervation  of 
the  limb  below  the  seat  of  fracture  must  receive  similar  careful 
attention  in  formulating  a  correct  diagnosis  and  in  determining  the 
existence  or  absence  of  injury  to  any  of  the  principal  nerves  by 
crushing,  cutting,  tearing,  or  compression.  In  order  to  arrive  at 
rational  correct  diagnostic  conclusions,  it  is,  therefore,  necessary 
not  only  to  establish,  if  possible,  and  without  detriment  to  the  pa- 
tient, the  existence- of  the  compound  nature  of  the  injury,  but  it 
is  likewise  essential  in  the  interest  of  the  patient,  as  well  as  for  the 
protection  of  the  reputation  of  the  practitioner,  to  establish  the 
extent  of  the  fracture  of  the  bone  or  bones,  and  especially  of  the 
injury  to  the  soft  tissues. 

Pathology. — The  acute  pathology  of  a  recent  compound  frac- 
ture is  characterized  by  the  comminution  of  the  fractured  bone, 
so  frequently  present,  crushing  of  medullary  tissue,  and  laceration 
of  the  soft  tissues  overlying  or  surrounding  the  seat  of  fracture. 
Owing  to  the  manner  in  which  such  injuries  are  produced,  hemor- 
rhage is  seldom  profuse.  A  certain  amount  of  extravasation  of 
blood,  however,  is  always  present  about  the  fractured  ends  of  the 
bones,  caused  by  hemorrhage  from  the  medullary  tissue  and  from 
the  torn  or  crushed  tissues  from  the  vessels  injured  by  the  fractur- 
ing force.  In  gunshot  fractures  implicating  large  blood-vessels  the 
hemorrhage  is  usually  profuse,  and  demands  the  first  attention  of 
the  surgeon.  If  any  of  the  large  blood-vessels  are  severed  by  the 
sharp  fragments,  hemorrhage  will  present  itself  as  one  of  the  most 
conspicuous  symptoms  of  the  accident.  If  the  fracture  is  the  re- 
sult of  traction  force,  some  of  the  large  arteries  may  become  par- 
tially occluded  immediately  after  the  accident  by  narrowing  of  the 
lumen  of  the  vessel  by  the  torn  intima,  a  condition  that  later  is 
almost  sure  to  result  in  complete  obliteration  of  the  vessel  by 
thrombus  formation.  The  peripheral  circulation  may  become  seri- 
ously embarrassed  by  compression  of  the  principal  blood-vessels, 
caused  by  displaced  fragments.  In  crushing  injuries  the  skin  may 
show  but  slight  indications  of  the  extent  of  injury  to  the  bone  and 


PATHOLOGY.  5  I  5 

the  soft  tissues  interposed  between  it  and  the  skin.  The  pressure 
and  extent  of  injury  to  the  principal  nerves  at  the  seat  of  fracture 
must  be  thoroughly  investigated  at  the  time  the  first  examination  is 
made.  The  sensation  of  the  parts  supplied  by  the  different  nerves 
below  the  seat  of  injury  must  be  carefully  tested  for  this  special 
purpose.  There  is  every  reason  to  believe  that  this  part  of  the 
examination  is  frequently  overlooked,  and  it  is  therefore  not  strange 
that  startling  results  will  occasionally  be  seen  when  least  expected, 
owing  to  the  incompleteness  of  the  first  examination.  Careful  in- 
spection and  digital  exploration  under  strict  aseptic  precautions  are 
necessary  to  ascertain  the  presence  and  exact  location  of  foreign 
bodies  in  the  wound,  to  enable  the  surgeon  to  proceed  intelligently 
when  he  undertakes  the  disinfection  of  the  wound. 

Fat  embolism  is  a  somewhat  rare  complication  of  fractures,  but 
in  anv  considerable  number  of  cases  of  compound  fractures  re- 
ported it  figures  as  a  cause  of  death.  It  is  most  likely  to  occur  in 
cases  in  which  the  medullary  tissue  is  extensively  crushed,  but  it 
has  also  been  observed  in  isolated  simple  fractures.  The  urine 
should  be  examined  daily  for  at  least  three  weeks.  The  more  fat 
there  is  in  the  urine,  the  less  circulates  in  the  blood.  Rapid  respi- 
ration, cyanosis,  and  subnormal  temperature  are  the  most  reliable 
indications  of  the  existence  of  this  grave  complication.  Groube 
reports  a  case  of  fatal  fat  embolism  in  which  the  first  symptoms 
set  in  thirteen  days  after  the  accident.  The  patient  was  a  railroad 
employee,  the  subject  of  multiple  fractures  and  severe  contusions 
which  he  sustained  in  a  collision.  The  postmortem  showed  many 
of  the  pulmonary  capillaries  completely  blocked  with  globules  of 
fat.  It  is  well  known  that  compound  fractures,  as  a  rule,  require 
a  longer  time  for  bony  consolidation  to  take  place  than  do  subcuta- 
neous fractures.  The  importance  of  furnishing  bones  deprived  of 
periosteum  with  moisture  to  prevent  dry  necrosis,  especially  in  the 
case  of  compound  fractures,  is  shown  by  Lesser  experimentally 
and  clinically.  He  found,  in  a  number  of  cases,  the  bone-ends 
divested  of  their  periosteal  covering  weeks  after  the  fracture 
occurred,  presenting  a  w^hite,  absolutely  dead  appearance,  with  no 
attempt  whatever  at  callus  production  or  the  formation  of  a  line 
of  demarcation.  To  prevent  such  an  occurrence  it  is  important 
to  furnish  the  exposed  bone  with  moisture — by  a  blood-clot  or 
moist  dressing.  If  this  condition  is  developed,  the  superficial 
necro.sed  bone  mu.st  be  removed  with  the  chisel  and  hammer, 
otherwi.se  callus  formation  will  be  unduly  delayed  or  perhaps  en- 
tirely lacking. 

The  immediate  infection  of  the  wound,  it  may  be  .stated  broadly, 
may  be  brought  about  by  any  of  the  pyogenic  microbes,  if  present 
in  the  wound  in  sufficient  number  and  if  of  the  required  degree  of 
virulence.  In  his  experimental  work  on  comi:>ound  fractures  Ron- 
cali  demon.strated  the  presence  of  the  bacillus  cedematis  maligni, 
the  bacillus  pseudo-cedematis  maligni,  the  bacillus  coli  commune, 


ci6  COMPOUND    FRACTURES. 

the  staphylococcus  pyogenes  aureus,  and  the  streptodiplococcus 
septicus.  He  describes  the  various  phases  of  the  infective  process 
caused  by  the  different  pyogenic  microbes.  In  the  majority  of 
cases  a  mixed  infection  will  be  found  :  in  the  gravest  cases  a  com- 
bination of  pyogenic  microbes  and  putrefactive  bacilli.  Primary 
infection  in  a  compound  fracture  usually  presents  itself,  as  in  any 
other  wound,  within  forty-eight  hours  after  the  receipt  of  the  injury. 
The  pathologic  developments  after  infection  has  occurred  depend 
largely  on  the  nature  of  the  microbic  cause.  Staphylococcus  infec- 
tion usually  terminates  in  localized  suppuration  and  limited  necrosis 
of  the  ends  of  the  fractured  bone.  Streptococcus  infection,  as 
either  an  isolated  infection  or  in  combination  with  staphylococcus 
infection,  generally  terminates  in  more  diffuse  phlegmonous  inflam- 
mation, profuse  suppuration,  and  more  extensive  traumatic  osteo- 
myelitis. Infection  with  any  of  the  putrefactive  bacilli  in  combi- 
nation with  the  effects  of  pyogenic  microbes  results  in  diffuse  in- 
flammation, extensive  edema,  and  the  production  of  more  or  less 
emphysema  and  fetid  pus. 

The  inflammatory  swelling  that  follows  so  promptly  in  case  a 
compound  fracture  becomes  infected  is  one  of  the  prolific  causes  in 
the  production  of  conditions  that  retard  the  process  of  repair,  and 
not  infrequently  necessitate  intermediary  or  secondary  amputation. 
The  inflammatory  swelling,  and  the  tension  caused  by  it,  is  often 
an  important  element  in  diminishing  the  arterial  blood  supply  to 
the  limb  below  the  seat  of  fracture  and  in  determining  venous  con- 
gestion, conditions  that  frequently  result  in  gangrene.  Fortunately, 
the  traumatic  osteomyelitis  in  such  cases  is  usually  limited  to  the 
ends  of  the  fractured  bones,  but  it  always  interferes  with  ideal 
repair,  retarding  callus  formation,  and  in  the  majority  of  cases 
results  in  necrosis  of  greater  or  less  extent.  The  secondary  sup- 
purative periosteitis  that  follows  osteomyelitis  of  the  same  type  in- 
terferes with  bony  consolidation  at  the  usual  time,  as  callus  forma- 
tion does  not  commence  until  the  acute  suppurative  process  has 
subsided.  Eventually,  profuse  callus  production  usually  takes  place, 
part  of  which  is  concerned  in  the  formation  of  an  involucrum 
around  the  necrosed  bone.  If  the  periosteum  has  been  extensively 
destroyed  by  the  trauma,  or  subsequently  by  the  suppurative  peri- 
osteitis, the  opening  in  the  involucrum  is  generally  large  enough 
to  admit  of  the  spontaneous  elimination  of  the  necrosed  bone  after 
it  has  become  separated  from  the  living  bone  by  a  tedious  process 
of  granulation.  If  the  reverse  is  the  case,  the  removal  of  the 
sequestrum  and  the  ultimate  recovery  of  the  patient  depend  on  the 
timely  intervention  of  the  surgeon.  A  compound  fracture  that  has 
become  infected  results  in  the  production  of  pathologic  changes  at 
the  seat  of  fracture  that  may  eventuate  at  any  time  in  relapsing 
attacks  of  osteomyelitis,  in  the  same  manner  and  for  the  same 
reasons  as  after  an  attack  of  spontaneous  infective  osteomyelitis. 
The  retardation  of  union  by  bony  callus  in  infected  compound  frac- 


PROGNOSIS. 


517 


tures  and  the  frequency  of  pseudarthrosis  are  readily  explainable 
if  we  consider  the  important  role  that  the  medullary  tissue  is  called 
upon  to  assume  in  the  definitive  repair  of  a  fracture.  Permanent 
enlargement  of  the  bone  is  to  be  expected  in  all  cases  of  compound 
fractures  in  which  suppuration  precedes  the  process  of  repair. 
Septic  thrombophlebitis  at  the  seat  of  a  compound  infected  fracture 
is  one  of  the  most  frequent  fatal  complications  of  such  accidents, 
as  it  precedes  and  constitutes  the  direct  cause  of  pyemia.  Septic 
intoxication  and  infection,  perhaps  even  more  frequent  causes  of 
death  in  such  cases,  result  from  streptococcus   or  mixed  infection. 


Fig.  321. — Compound  comminuted 
fracture  of  the  femur.  Necrosis  of  frac- 
tured ends  and  detached  fragments. 
Death  after  six  weeks  (Bruns). 


Fig.  322. — Consolidated  commin- 
uted compound  fracture  of  the  femur, 
with  necrosed  fragments  embedded  in 
the  calhis  (Brunsj. 


Ferment  intoxication  is  a  frequent  accompaniment  of  simple  frac- 
tures, and  usually  appears  in  a  more  marked  form  in  compound 
fractures.  It  is  caused  by  the  absorption  of  fibrin  ferment  from  the 
extravasated  blood,  and  is  observed  as  an  earlier  complication  of 
compound  fractures  than  septic  infection  or  pyemia. 

Prognosis. — The  danger  to  limb  and  life  is  determined  more 
by  the  extent  of  injury  to  the  soft  tissues  and  by  wound  infection 
than  by  the  number  of  fractures  or  the  degree  of  comminution  of 
the  fractured  bone.  Kxtensive  lo.ss  of  skin,  crushing  of  muscles, 
and  tearing  of  any  of  the  large  vessels  and  nerves  must  be  looked 
for,  more  especially  in  crushing  injuries,  and  when  present  to  any 
extent  as  isolated    or  combined    injiu'ies   will    often   furnish    ample 


5l8  COMPOUND    FRACTURES. 

ground  for  primary  amputation.  In  estimating  the  gravity  of  the 
injury  a  most  thorough  and  searching  examination  into  the  condi- 
tion of  the  soft  parts  is  necessary,  for  the  purpose  not  only  of  for- 
mulating a  reliable  prognosis,  but  likewise  with  a  view  to  determin- 
ing upon  the  proper  treatment  to  be  pursued.  In  cases  of  extensive 
crushing  injuries  important  vessels  and  nerves  are  usually  impli- 
cated to  an  extent  incompatible  with  preservation  of  the  limb. 

The  time  intervening  between  the  receipt  of  the  injury  and  the 
rendering  of  efficient  first  aid  has  an  important  bearing  on  the  prog- 
nosis, as  has  been  shown  so  conclusively  by  the  statistics  of  Bruns, 
previously  quoted.  The  danger  of  infection  increases  with  time, 
and  is  m.uch  greater  after  the  lapse  of  from  twenty -four  to  forty- 
eight  hours  after  the  accident,  in  wounds  left  unprotected  for  that 
length  of  time.  The  presence  of  dirt  and  of  foreign  substances  of 
any  kind  in  the  wound  adds  to  the  gravity  of  the  prognosis  by 
increasing  the  danger  from  infection.  Some  surgeons  take  the 
ground,  at  the  present  time,  that  primary  amputation  should  never 
be  resorted  to,  as  they  claim  that  under  antiseptic  precautions  the 
danger  to  life  is  not  increased  by  delay,  and  that  by  waiting  for  the 
line  of  demarcation  to  become  established,  more  tissue  can  be  saved 
by  substituting  secondary  for  primary  amputation  in  case  a  muti- 
lating operation  be  made  necessary  by  the  occurrence  of  gangrene. 
This  position  is  too  extreme  even  at  the  present  time.  It  is  in  just 
such  cases  that  the  most  intelligent  and  rigorous  antiseptic  precau- 
tions will  frequently  fail  in  protecting  the  wound  against  infection, 
thus  adding  greatly  to  the  danger  to  life  from  septicopyemia.  It 
must  also  be  remembered  that  in  case  the  antiseptic  treatment  fails, 
the  inflammatory  conditions  that  follow  infection  may  necessitate  a 
higher  amputation  than  would  have  been  the  case  had  primary 
amputation  been  done. 

Conservatism  in  the  treatment  of  compound  fractures  has  be- 
come the  rule,  but  there  are  many  cases  where  the  indications  for 
amputation  as  a  life-saving  operation  are  so  clear  that  it  would 
be  folly  to  ignore  them  and  expose  the  patient's  life  to  the  addi- 
tional risks  of  sepsis  for  the  purpose  of  ascertaining  exactly  how 
much  of  the  limb  could  be  saved.  The  necessity  for  the  perfor- 
mance of  secondary  amputation  has  very  much  diminished  since 
the  antiseptic  treatment  of  compound  fractures  has  been  generally 
adopted,  but  it  occasionally  becomes  necessarj' — when  the  septic 
wound  complications  do  not  yield  to  antiseptic  treatment  and  life  is 
placed  in  jeopardy  from  profuse  suppuration  or  sepsis,  and  in  cases 
in  which,  owing  to  undiscovered  complications  or  the  intensity  of 
the  inflammation,  gangrene  follows  as  an  early  or  a  late  complication. 
From  a  prognostic  standpoint,  the  general  condition  of  the  patient, 
his  age,  and  his  habits  must  be  taken  into  careful  consideration 
before  positive  conclusions  are  reached.  A  vigorous  constitution 
and  a  satisfactory  condition  of  the  general  health  are  favorable 
conditions  when  we  come  to  estimate  the  gravity  of  the  injury. 


PRIMARY    AMPUTATION.  .         5^9 

Children  and  voung  adults  recover  more  rapidly  from  such  injuries 
^nuaien  auu  \«jui  j,  T,-,tf»mnprance  and  excesses  ol  all 

than  persons  advanced  m  years.      Intempeiance  ana 
Lnds  add  to  the  liability  of  infection   and   are  apt  to  letard   the 

^"T^lfmenT-The  modern  treatment  of  a  compound  fracture 
•  .  T^vv  resDonsibility  on  tlie  attending  surgeon.      Undei 

:^^ry^^^^st<^  in  recent  cases  he  is  expected  to  protect 
the  ^und  aoamst  infection,  and  the  patient  from  its  serious  im- 
tne  \\ouiiu  cij,aii.  Aff^.,- piiminat  no- the  cases  requu- 

'i^ise  trexpoe  the  patient  to  the  dangers   of  too  much  conse.- 

=':,m,  because  even  fn  case  the  Patient  survives  the  mjury  and  the 

I  .„K  il  «vpri  it  is  often  deformed  and  useless.     In  geneial,  tne 

.l-™;  of  the  vessels    nerves,  muscles,   skin,  and  neigl>bon„g 

puS'  sL°uld  i^flu^nci  'the  surgeon  .n  forming  an  opinion  as  to 

™' Prtal^  AmXaon:-How  the  indications  for  primary  am- 
..,ta~^^e\"?:  fonnulated  u,  the  past  ^^-^^^^'^'^ 
ihe  rules  laid  down  by  the  great  surgeon,  Sn  ^stley  Coope.  n 
e  lower  extremity  of  the  tibia  be  broken  uUosm  1  p.eces  e 
loose  port,ons  of  bone  o"g''' '".^^.^^J^t  o  th      omminut.on. 

and  tarsal  bones,  as  the  astragalus  and  os  "^^l-^'^', ^  J^^  °.^[";,'  ','3" 
amputation  will  be  required."  Ant,sept,c  surgerv  has  e "tudy  J'^^^' 
these  rules  Primary  amputation  m  rcce.it  cases,  m  acco,  dance 
whh  modern  Ic-ntimate  indications,  must  be  restricted  to  cases    n 

IcirtlK  fLturing  force  or  subsequent  -cident^have  resu^^  e 
injuries  that  would  be  likely  to  lead  to  arrest  °    '^^^    •;"','  ,'„f 
nutrition,  and  their  inevitable  result,  Sank'rene^     h^te  sn  e  loss  o 


520  COMPOUND    FRACTURES. 

the  femoral  or  brachial,  amputation  is  usually  a  justifiable  procedure. 
If  the  accompanying  vein  is  injured  at  the  same  time,  the  indication 
for  immediate  operation  is  more  urgent.  If  the  injury  of  vessels 
of  this  size  can  not  be  demonstrated  by  existing  hemorrhage,  inspec- 
tion and  digital  exploration,  under  strict  antiseptic  precautions, 
become  justifiable  diagnostic  procedures.  The  extent  of  vessel 
injury  should  be  carefully  ascertained  by  the  condition  of  the  per- 
ipheral circulation,  as  indicated  by  the  character  of  the  pulse,  by 
the  temperature,  and  by  the  color  of  the  surface  of  the  limb.  If  the 
intima  of  an  artery  of  any  considerable  size  has  been  torn  by  trac- 
tion force,  the  peripheral  pulse  will  be  found  smaller  immediately 
after  the  injury,  and,  as  has  been  pointed  out  by  von  Wahl  years 
ago,  a  bruit  can  be  detected  on  auscultation  over  the  injured  part 
of  the  vessel.  It  is  in  such  instances  that  complete  obstruction 
soon  sets  in  from  thrombus  formation,  thus  interfering  with  a  proper 
blood  supply  to  the  limb  below  the  seat  of  fracture.  The  extent 
of  nerve  injury  in  the  absence  of  visible  or  palpable  injury  must  be 
estimated  by  ascertaining  the  degree  of  loss  of  innervation,  both  of 
motion  and  sensation,  below  the  seat  of  fracture.  Examination 
concerning  vascular  and  nervous  disturbances  below  the  seat  of 
injury  has,  as  a  rule,  not  been  conducted  with  the  degree  of  thorough- 
ness necessary  to  estimate,  with  some  degree  of  certainty,  the  fate 
of  the  injured  limb. 

In  performing  primary  amputation  the  surgeon  must  be  careful 
not  to  include  in  the  flaps  any  of  the  tissues  that  have  been  seri- 
ously bruised  or  crushed.  For  the  purpose  of  securing  a  desirable 
stump,  and  with  a  view  to  saving  as  much  tissue  as  possible,  it  is 
often  necessary  to  modify  prescribed  methods  of  amputation  by 
taking  the  tissues  from  the  side  least  injured.  Typical  amputations 
as  described  in  our  text-books  often  are  not  adapted  to  meet  the 
local  indications  in  such  cases,  and  the  surgeon  must  exercise 
his  ingenuity  and  judgment  to  adapt  the  operation  to  the  injured 
limb,  and  not  the  injured  limb  to  the  operation,  in  justice  to  himself 
and  to  his  patient. 

Treatment  of  Wound. — The  most  responsible  and  important 
part  of  the  treatment  of  a  compound  fracture  consists  in  properly 
caring  for  the  wound.  The  wound  treatment  must  necessarily  vary 
in  accordance  with  the  manner  in  which  the  fracture  was  produced 
and  the  length  of  time  that  has  elapsed  since  the  injury  was 
received.  For  the  purpose  of  showing  the  recent  advancements 
in  this  part  of  the  treatment  of  compound  fractures,  only  a  few 
methods  of  wound  treatment,  practised  generally  and  by  the  best 
surgeons,  less  than  half  a  century  ago,  will  be  described  here. 
Sir  Astlcy  Cooper  spoke  very  highly  of  healing  of  the  wound 
under  a  scab.  For  this  purpose  he  employed  charpie,  which  was 
applied  to  the  wound  and  which,  with  the  blood  with  which  it 
became  saturated,  was  after  a  time  converted  into  a  dry  crust  that 
was  permitted  to  remain,  thus  protecting  the   wound   against   late 


TREATMENT    OF    WOUND.  521 

infection  from  without.  Trendelenburg,  as  late  as  1873,  recom- 
mended this  method  in  strong  terms,  and  maintained  that  it  always 
succeeded  in  retarding  suppuration  for  at  least  ten  days.  He  be- 
lieved, at  that  time,  that  the  substitution  of  strong  carbolic  acid 
for  the  blood  in  making  the  crust  did  not  materially  influence  for 
the  better  the  healing  of  the  wound.  Cold  and  hot  water  has  had 
an  extensive  use  in  the  treatment  of  wounds  of  compound  fractures. 
Chassaignac  favored  the  use.  of  his  panscmoit  par  occliisioii,  sealing 
the  wound  with  strips  of  diachylon  plaster,  relying  on  Scultet's 
dressing  in  securing  fixation.  A.  Guerin  made  an  advance  in  the 
right  direction  when  he  enveloped  the  limb  in  a  thick  la\er  of 
cotton,  which  he  did  not  remove  for  two  or  three  weeks,  even  in 
the  event  of  profuse  suppuration.  This  method  of  treatment  was 
extensively  practised  in  France  during  the  war  with  Germany. 
Oilier  improved  upon  this  treatment  by  applying  a  fixation  dressing 
over  the  cotton.  Guyon  sealed  the  wound  with  collodion  and 
cotton.  Continuous  irrigation  in  suppurating  compound  fractures 
was  first  practised  by  Josse  in  1834.  Langenbeck  favored  perma- 
nent immersion  in  warm  water.  Gurlt  advocated  the  local  use  of 
cold  and  a  somewhat  rigorous  antiphlogistic  treatment,  including 
bleeding  in  some  cases  and  local  abstraction  of  blood  by  leeching  ; 
in  cases  in  which  the  patient  showed  signs  of  depression,  stimulants 
and  the  local  use  of  poultices,  warm-water  compress,  camphor 
wine,  dilute  creasote,  turpentine,  and  vegetable  charcoal.  Larrey 
was  partial  to  the  use  of  camphor  preparations  in  the  treatment  of 
the  wound. 

All  the.se  methods  accomplished  little  in  preventing  wound 
infection  except  in  the  simplest  cases.  Profuse  suppuration  and 
septicopyemia  continued  to  maintain  the  fearful  mortality  and  to 
force  the  surgeon  frequently  to  resort  to  secondar>'  amputation, 
often  in  a  vain  effort  to  save  life,  until  Lister  and  his  early  fol- 
lowers taught  us  the  value  of  more  effective  prophylactic  measures 
in  guarding  against  wound  infection.  Many  of  the  surgeons  of  the 
present  day  remember  the  first  efforts,  which  consisted  in  the  use 
of  carbolizcd  putty  and  carbolized  oil.  It  required  time  and  expe- 
rience to  reap  the  full  benefits  of  the  anti-septic  treatment  of  wounds 
as  applied  to  compound  fractures.  Reyher  was  one  of  the  first  to 
bring  to  the  attention  of  the  profession  the  value  of  the  antiseptic 
treatment  of  compound  fractures,  combined  with  immobilization,  in 
the  management  of  gunshot  wounds  in  military  surgery.  The 
early  statistics  on  this  subject  by  Reyher  and  von  Hergmann  were 
a  revelation  to  every  surgeon  who  had  battled  in  vain  for  years  in 
preventing  infection  in  such  ca.ses.  Moi.st  anti.septic  compresses 
have  been  u.sed  very  extensively,  and  the  results  have  been  encour- 
aging. Kocher  saturated  the  compress  with  a  -5-  of  I  per  cent, 
solution  ofchlorid  of  zinc;  von  Hergmann  used  a  ^  of  I  per  cent, 
solution  of  bichlorid  of  mercury,  but  most  of  the  surgeons  pre- 
ferred a  2^  per  cent,  carbolic  acid  solution.      Bardeleben  used  the 


522  COMPOUND    FRACTURES. 

moist  carbolized  jute  compress  on  a  large  scale  and  obtained  good 
results.  Thiersch  recommended  salicylated  cotton  or  jute.  Miin- 
nich  employed,  as  a  wound  dressing,  dry  carbolized  jute.  Maas 
obtained  the  best  results  by  subjecting  the  wound  and  adjacent 
parts  to  thorough  cleansing,  then  irrigating  the  wound  with  either 
a  2  ^  per  cent,  solution  of  carbolic  acid  or  a  yL  of  i  per  cent,  solu- 
tion of  bichlorid  of  mercury.  The  wound  is  then  covered  with  silk 
protective,  and  dressed  with  corrosive  sublimate,  chlorid  of  sodium 
gauze. 

Modern  Treatment. — The  antiseptic  treatment  of  compound 
fractures  can  not  be  said  to  have  reached  perfection.  Much  has 
been  done  in  simplifying  and  making  more  efficient  the  antiseptic 
measures  employed  in  preventing  wound  infection  since  the  first 
efforts  were  made  in  this  direction,  but  we  have  reason  to  believe 
that  the  methods  will  undergo  further  modifications,  and  additional 
improvements  be  made  that  will  materially  reduce  the  present  low 
mortality,  and  make  a  recourse  to  secondary  amputation  even  less 
frequent  than  at  the  present  time.  Since  the  antiseptic  treatment 
of  compound  fractures  has  been  generally  adopted,  triumphant 
results  have  been  reported  from  nearly  all  parts  of  the  world.  The 
statistics  given  elsewhere  furnish  the  most  convincing  proof  of  the 
advancements  that  have  been  made  in  this  department  of  surgery. 

The  modern  antiseptic  treatment  must  vary  according  to  the 
nature  of  the  wound  and  the  manner  in  which  it  was  inflicted.  As 
a  general  rule,  it  may  be  stated  that  the  first  dressing  decides  the 
fate  of  the  patient  and  determines  the  process  of  wound  healing. 
The  treatment  of  the  wound  is  of  far  greater  consequence  than  that 
of  the  fracture  itself,  more  especially  during  the  first  two  weeks. 
A  combination  of  most  thorough  antiseptic  treatment  of  the  former, 
immediate  and  perfect  reduction  of  the  latter,  followed  by  fixation 
of  the  fractured  limb  by  some  kind  of  plastic  splint,  yields  the  best 
results.  Whenever  there  is  any  prospect  of  obtaining  primary 
healing  of  the  wound,  the  attempt  should  be  most  faithfully  made. 
In  punctured  and  gunshot  fractures  and  when  the  wound  is  small 
and  clean  cut,  the  surrounding  skin  for  a  distance  of  several  inches 
should  be  shaved  and  thoroughly  disinfected  by  scrubbing  with 
hot  water  and  potash  soap,  then  with  alcohol,  and  lastly  with  a  5 
per  cent,  carbolic  acid  or  a  i  :  1000  bichlorid  of  mercury  solution. 
If  the  bone  projects  from  the  wound,  the  part  protruding  should 
be  included  in  the  disinfection  before  reduction  is  made,  as  other- 
wise infection  may  be  caused  by  the  reduction.  Such  fractures 
must  never  be  explored,  and  the  wound  should  not  be  enlarged 
unless  reduction  is  impossible  without  so  doing  or  complications 
present  themselves  that  demand  it.  Resection  of  the  projecting 
fragment  is  seldom  necessary,  as  reduction  can  usually  be  effected 
under  the  influence  of  an  anesthetic.  It  is  in  cases  of  this  kind  and 
in  gunshot  fractures  that,  as  a  rule,  the  wound  beneath  the  skin  is 
aseptic.      Suturing  of  such  wounds  should  be  avoided. 


MODERN    TREATMENT.  523 

The  wound  properly  disinfected,  is  dressed  by  applying  an  anti- 
septic occlusion  dressing.  For  this  purpose  nothing  is  more  effi- 
cient than  a  nonirritating  effective  antiseptic  powder,  composed 
of  four  parts  of  boric  acid  to  one  part  of  salic}'lic  acid,  and  a  com- 
press of  aseptic  absorbent  cotton.  Cotton  is  preferable  to  gauze, 
as  it  serves  as  a  more  efficient  filter,  and  with  the  powder  and  blood 
is  soon  converted  into  a  dry  crust  that  seals  the  wound  hermeti- 
cally and  excludes  it  from  the  entrance  of  pathogenic  microbes. 
About  a  teaspoonful  of  the  borosalicylic  powder  is  placed  on 
the  wound,  and  the  cotton  compress  is  applied  and  retained  with  a 
gauze  roller,  or,  if  there  is  any  danger  of  it  becoming  displaced,  it 
is  fastened  in  place  with  a  strip  of  adhesive  plaster  before  the 
bandage  is  applied.  The  dressing  should  not  be  disturbed  until  the 
wound  is  healed,  unless  signs  and  symptoms  indicate  the  existence 
of  infection.  Should  infection  follow  this  treatment,  removal  of 
the  dressing,  enlargement  of  the  wound,  counteropenings,  efficient 
tubular  drainage,  energetic  secondary  disinfection,  and  substitution 
of  the  hot  antiseptic  compress  for  the  dry  dressing  is  the  proper 
course  to  pursue.  If  wound  infection  does  not  occur,  the  com- 
pound fracture  is  practically  converted  at  once  into  a  subcutaneous 
fracture,  and  should  be  treated  as  such.  P.  Bruns  recommends 
for  similar  cases  a  powder  composed  of — 

Carbolic  acid, 25  parts. 

Colophonium, 60      " 

Stearin, 13      " 

Precipitated  carbonate  of  lime, 700      " 

I  have,  however,  used  the  borosalicx'lic  powder,  in  the  propor- 
tion specified,  on  an  extensive  scale,  both  in  civil  and  militar\'  prac- 
tice, and  have  been  so  much  gratified  with  the  results  that  I  can 
recommend  it  most  emphatically  as  a  local  application  in  such  cases, 
used  in  the  manner  described. 

In  lacerated  and  contused  wounds  the  first  and  most  important 
duty  in  rendering  first  aid  is  to  subject  the  wound  to  an  absolutely 
efficient  and  safe  primaiy  disinfection.  This  can  be  done  only  by 
fir.st  shaving  and  disinfecting  the  part  of  the  limb  that  is  the  seat 
of  the  fracture,  and,  if  the  fracture  is  near  a  joint,  as  much  of  the 
adjacent  part  of  the  limb  or  trunk  as  will  be  covered  by  the  large 
anti.septic  dressing.  A  common  error  made  in  the  management  of 
such  ca.ses  is  that  the  surface  disinfection  is  not  extended  far  enough. 
If  the  wound  disinfection  can  not  be  made  with  sufficient  thorough- 
ness without  the  use  of  an  anesthetic,  it  is  preferable  to  anesthetize 
the  patient  rather  than  neglect  meeting,  to  the  fullest  extent,  the 
most  important  indications  in  the  treatment  of  the  wound.  All  such 
'ivoimds  iinist  be  regarded  and  treated  as  infected  tvonnds.  The 
sources  of  infection  are  so  numerous  that  few  wounds,  if  any,  escape. 
The  vulnerating  implement,  the  clothing,  the  torn  skin,  the  expo- 
sure of  the  wound  to  dirt  and  air,  are  only  some  of  the  sources 
from  which  pathogenic  microbes  are  introduced   into  the   wound. 


524  COMPOUND    FRACTURES. 

The  surgeon  zvho  makes  the  first  examination  and  applies  the  first 
dressing  must  disinfect  his  hands  as  carefully  as  if  he  intended  to  open 
the  skull  or  the  abdomen.  In  most  instances  the  wound  is  larger 
underneath  the  skin  than  on  the  surface,  and  a  thorough  primary 
disinfection  is  out  of  question  without  enlarging  the  external  wound 
sufficiently  to  expose  every  nook  and  corner  for  the  direct  applica- 
tion of  the  antiseptic  solution.  After  free  exposure  of  the  wound 
surface  the  surgeon  removes  blood-clots,  foreign  bodies,  and  loose 
fragments  not  required  in  a  satisfactory  process  of  repair.  If  on 
hand,  peroxid  of  hydrogen  should  now  be  poured  into  the  wound  ; 
if  not,  antiseptic  irrigation  with  a  hot  2^  per  cent,  carbolic  acid 
solution  or  a  solution  of  bichlorid  of  mercury,  I  :  lOOO,  should  at 
once  be  commenced  and  continued  until  the  wound  is  surgically 
clean.  I  have  more  faith  in  carbolic  acid  than  in  sublimate  as  a 
disinfecting  agent  in  the  treatment  of  accidental  wounds,  as  it  pene- 
trates the  tissues  more  deeply  and  leaves  them  in  a  more  favorable 
condition  for  the  healing  of  the  wound  by  primary  intention.  In 
extensive  lacerated  wounds  it  is  advisable  to  cut  away  the  torn 
margins,  converting  the  wound  as  nearly  as  possible  into  an  incised 
wound,  better  adapted  for  successful  suturing.  The  deeper  portions 
of  the  wound  can  be  treated  in  the  same  manner  if  they  are  covered 
with  torn  tissue  that  would  be  in  the  way  of  primary  union,  for  the 
purpose  of  preparing  the  surfaces  for  buried  sutures,  which  can 
often  be  employed  to  advantage  in  diminishing  the  size  of  the 
wound  and  the  space  requiring  drainage.  The  etagen,  or  buried 
suture,  of  aseptic  catgut  is  of  special  value  in  suturing  vascular 
tissue  over  the  detached  fragments  if  the  fracture  is  a  comminuted 
one.  The  disinfection  must  extend  to  the  seat  of  fracture.  All  the 
loose  fragments  shoidd  be  removed,  disinfected  in  the  carbolic  acid 
solution,  and  immersed  in  a  warm  saline  solution,  ready  for  reim- 
plantation after  the  wound  has  been  disinfected. 

Counteropenings  may  become  necessary  for  drainage  if  the 
wound  is  an  irregular  one,  and  dead  spaces  can  not  be  avoided  by 
buried  sutures.  Tubular  drains  well  fenestrated  must  be  employed 
for  this  purpose.  The  counteropenings  are  made  by  tunneling  the 
soft  tissues  from  the  side  of  the  wound  with  a  pair  of  locked  hemo- 
static forceps,  which  are  pushed  in  the  desired  direction  until  the 
skin  over  the  point  of  the  instrument  is  raised  in  the  form  of  a  cone, 
which  is  then  incised  at  its  base  on  one  side,  and  the  instrument 
made  to  emerge  from  the  wound  ;  the  drain  is  grasped  and  brought 
into  the  wound  with  the  return  of  the  forceps.  The  tube  should 
not  project  further  into  the  wound  than  the  cavity  it  is  intended  to 
drain.  In  large  wounds  multiple  counteropenings  may  become 
necessary.  For  this  special  purpose  the  drains  should  never  be 
thinner  than  the  little  finger,  and  should  not  be  disturbed  until  the 
time  for  infection  to  take  place  has  elapsed — that  is,  for  from  forty- 
eight  to  seventy-two  hours.  The  zvound  itself  must  never  be  entirely 
closed  by  suturing,  as  drainage  is  always  required  in  such  cases,  and 


MODERN    TREATMENT. 


525 


Diust  be  maintained  2i)itil  all  danger  from  infecticvi  lias  passed.  The 
wound  is  drained,  in  preference,  with  a  single  strip  of  iodoform 
gauze,  the  projecting  end  of  which  is  secured  by  a  large,  aseptic 
safety-pin.  Two  ways  present  themsehes  for  dressing  the  wound 
— (i)  with  the  dry  dressing;  (2)  with  the  moist  dressing.  The 
surgeon  must  discriminate  carefulh'  in  making  the  selection.  The 
t}-pical  dry  absorbent  antiseptic  gauze  dressing  is  indicated  in 
wounds  that,  from  their  size,  from  the  time  that  has  elapsed  from 
the  receipt  of  the  injury  to  the  first  dressing,  and  from  the  thorough- 
ness with  which  the  primary  disinfection  was  made,  we  have  reason 
to  expect  will  heal  by  primary  intention.  In  applying  such  a  dress- 
ing a  few  layers  of  iodoform  gauze  should  be  placed  next  to  the 
wound,  the  bulk  of  the 
dressing  being  made  of 
sterile  gauze,  and  over 
and  around  it  a  thick 
cushion  of  absorbent 
cotton  should  be  placed. 
The  dressing  should 
be  a  copious  one,  and 
should  be  retained  in 
place  by  a  gauze  roller. 
So  copious  a  dressing 
exerts  an  equable  elastic 
pressure,  so  important 
an  element  in  securing 
muscular  rest  and  in 
holding  in  accurate  and 
uninterrupted  contact 
the  wound  surfaces. 
After  the  dressing  has 
been  applied  and  the 
fractured  bone  placed  in 
proper  position,  a  fixa- 
tion .splint  of  some  kind 
should  be  applied  over 
the  wound  dressing.  In 
case  no  infection  sets  in  the  first  dressing  may  remain  in  place  for 
two  or  more  weeks.  Should  the  dressing  become  saturated  with 
blood,  the  surface  may  be  .sprinkled  with  borosa]ic)'lic  powder,  and 
an  additional  layer  of  cotton  be  applied,  to  make  an  early  change 
of  dre.ssing  unneces.sary.  Nothing  is  more  harmful  in  the  treat- 
ment of  a  compound  fracture  than  meddlesome  surgery  ;  the  longer 
a  dressing  can  remain  with  impunity,  the  greater  is  the  probability 
of  avoiding  infectif)n,  and  the  better  are  the  chances  of  obtaining 
primary  healing  of  the  wound. 

The  surgeon  can  not  be  too  watchful  in  the  after-treatment  of  a 
compound  fracture.      He  must,  day  after  day,  look  for  evidences  of 


Fig-  323- 


-Starke's  apparatus  for  permanent 
irrigation. 


526 


COMPOUND    FRACTURES. 


infection.  A  rise  in  temperature  during  the  first  twenty-four  hours 
usually  means  ferment  intoxication  ;  after  that  time  it  suggests 
septic  infection.  In  fermentation  fever  the  subjective  symptoms  are 
generally  nil ;  in  sepsis  they  correspond  in  intensity  with  the  degree 
of  intoxication.  The  condition  of  the  tongue  is  of  more  diagnostic 
importance  than  the  character  and  frequency  of  the  pulse  in  dis- 
criminating between  fermentation  fever  and  sepsis.  In  septicemia 
the  tongue  is  dry  and  usually  brown  ;  in  fermentation  fever  it 
is  moist  and  coated.  If,  from  the  local  and  general  symptoms, 
it  becomes  apparent  that  the  wound  has  become  infected,  no  time 
must  be  lost  in  removing  the  dressing  and  in  making  additional 
provision  for  drainage.  Secondary  disinfection  is  generally  incom- 
plete and  unsatisfactory.      If  the  wound  has  been  sutured,  every 


F'g-  324- — Immobilization,  suspension,  drainage,  and  permanent  antiseptic  irrigation  of 

tlie  Icnee-joint. 

stitch  must  be  removed  and  drainage  established  Avherever  it  appears 
necessary.  The  moist  antiseptic  compress  must  invariably  take 
the  place  of  the  dry  dressing,  and  frequent  antiseptic  flushings 
become  indispensable.  It  is  advisable,  under  such  circumstances, 
to  replace  the  more  energetic  antiseptic  solutions,  such  as  carbolic 
acid  and  corrosive  sublimate,  by  Thiersch's  solution  or  a  saturated 
solution  of  the  acetate  of  aluminum,  as  the  former,  used  in  large 
quantities  and  at  short  intervals,  might,  and  often  do,  result  in 
intoxication  that  may  prove  disastrous  and  even  fatal.  The  anti- 
septic irrigation  should  be  preceded  by  the  injection  of  peroxid  of 
hydrogen.  If  suppuration  does  not  yield  promptly  to  this  treat- 
ment, continuous  irrigation  with  either  of  the  mild  antiseptic  solu- 


DIRECT    FIXATION    OF    FRAGMENTS. 


527 


tions  must  be  instituted  at  once,  and   has  often,  in  my  experience, 
been  the  means  of  averting  death  from  sepsis  and  in  preventing  the 
necessity  of  a  secondary  amputation.      Should  this  treatment  not 
make  a  prompt  impression  by  improving  the  local  conditions  and 
b)-  ameliorating  the  general  symptoms,  the  propriety  of  performing 
a  secondary  amputation  must  be  considered,  with  a  view  to  prevent- 
ing death  from  septicopj-emia.      Continuous  irrigation   can  be  ex- 
temporized in  a  very  simple   and  yet  efficient  manner.      A  piece  of 
rubber  tubing,  six  or  eight  feet  in  length,  can  be  used  as  a  siphon, 
or  may  be  connected  with  an  opening  on  one  side  near  the  bottom 
of  the  reservoir  holding  the  antiseptic  solution,  and  with  one  of  the 
drains  in  the  wound.     A  stop-cock  or  clothes-pin  is  used  to  regulate 
the  size  and  force  of  the  stream.      The  solution  must  be  kept  at  a 
temperature  of  blood  heat,  or,  still  better,  a  little 
higher,  and  if  more  than  one  drain  is  employed, 
the  point  of  irrigation  is  changed  at  certain  inter- 
vals from  one  to  the  other.      If  man}-  drains  have 
been  used,  it  is  advisable  to  connect  them  with 
several  siphon   tubes  so  as  to  flush  the  different 
parts  of  the  wound  continuously.      By  suspend- 
ing the  limb,  properly  immobilized,  and  placing 
underneath  it  a  rubber  sheet,  the  fluid  is  drained 
into  a  vessel  by  the  side  of  the  bed.      A  com- 
press saturated  with  the  same   solution  is  made 
to  cover  the  wound  and  is  to  be  changed  several 
times   a   day.     The   general    treatment   in    such 
cases   must  be  stimulating  and  tonic,  supported 
by  a  concentrated  and   nutritious  diet.      Should 
an  adjacent  joint  become  involved,  free  drainage 
and  continuous  irrigation   constitute  the  proper 
local   treatment.      Progressive  phlegmonous   in- 
flammation calls  for  free  drainage   and  frequent 
or  continuous  irrigation.      It  is  in  cases  of  this 
kind  that  signal   benefit  has  been   derived  from 
applying  a  compress  saturated  with  a    i  :  1000 
solution  of  either  the  lactate  or  the  citrate  of  silver.     If  a  secondary 
amputation  becomes   necessary,  the  operation   must  be  performed 
through  healthy  ti.ssue,  at  a  safe  distance  from  the  infected  territory. 
Direct   Fixation   of   Fragments. — Attempts  to  inmiobilize  the 
fragments  by  direct  means  of  fixation  would  appear  to  be  a  rational 
course  to  pursue  in  the  treatment  of  compound  fractures.     In  cases 
in  which  it  is  apparent  that  the  fragments  can  not  be  retained  in  a 
desirable  position  by  the  usual  methods  of  immobilization,  there  is 
.strong  temptation  to  utilize  the  existing  wound  for  the  purpose  of 
gaining  access  to  the  .scat  of  fracture  and  resort  to  direct  means  of 
fixation.      This  method  of  treating  compound  fractures  has  many 
ardent  supporters,  but,  for  obvious   reasons,  it  has  failed  to  receive 
general   recognition.      The  additional   trauma  sustained   in   uniting 


F'g-325— Volk- 

mann'  s  dropping  tube 
for  continuous  wound 
irrigation. 


528  COMPOUND    FRACTURES. 

the  fractured  bone-ends  by  direct  measures  must  be  taken  into 
account  before  resorting  to  wiring  or  other  methods  of  direct  fixa- 
tion. Such  a  procedure  may  also  become  an  additional  source  of 
infection.  Direct  fixation  in  compound  fractures,  under  ordinary 
circumstances,  is  absolutely  contraindicated,  and  even  at  the  present 
time  should  be  restricted  to  cases  in  which  an  external  fixation 
dressing  proves  inadequate  to  hold  the  fragments  in  a  satisfactory 
position,  and  would,  consequently,  if  relied  upon,  result  in  vicious 
union.  The  indications  for  operative  interference  in  such  cases 
would,  in  other  words,  be  the  same  as  in  subcutaneous  fracture  of 
a  similar  nature  and  in  the  same  locality.  If  the  wound  is  large 
and  the  seat  of  fracture  readily  accessible,  direct  fixation  is  indi- 
cated only  in  cases  in  which  the  usual  treatment  of  a  similar  sub- 
cutaneous fracture,  by  established  methods,  would  yield  an  unsat- 
isfactory functional  result.  The  most  frequent  indications  for  some 
sort  of  direct  fixation  are  presented  by  cases  of  extensive  comminu- 
tion, complicated  by  a  large  wound.  It  is  in  such  instances  that  all 
the  loose  fragments  of  bone  should  be  temporarily  removed,  disin- 
fected in  a  warm  2j^  per  cent,  solution  of  carbolic  acid  or  a 
I  :  1000  bichlorid  solution,  and  subsequently  immersed  in  a  warm 
normal  salt  solution,  in  readiness  for  reimplantation  after  the  wound 
has  been  thoroughly  disinfected.  The  temporary  removal  of  the 
loose  fragments  enables  the  surgeon  to  complete  the  primary  disinfec- 
tion of  fragments  and  wound  witli  a  greater  degree  of  thoroughness, 
and  the  fragments  are  often  removed  from  localities  where  tlieir  pres- 
ence woidd  be  Jiarmfid  and  tvhere  they  can  not  take  part  in  the  subse- 
quent process  of  repair.  It  is  somewhat  strange  that  all  the 
modern  text-books  on  surgery  continue  to  insist  that  all  loose  frag- 
ments should  be  removed,  in  the  face  of  the  fact  that  the  majority 
of  compound  fractures,  under  antiseptic  treatment,  are  repaired  in 
the  same  manner  as  subcutaneous  fractures.  The  time  has  cer- 
tainly come  to  make  the  attempt  to  preserve  as  many  of  these  frag- 
ments as  are  necessary  for  a  satisfactory  restoration  of  the  continuity 
of  the  fractured  bone.  That  this  can  be  done  successfully  has 
been  demonstrated  by  experimentation  and  clinical  observation. 
Jakimowitsch  made  twelve  experiments  on  animals  to  determine  the 
fate  of  completely  detached  fragments  of  the  long  bones,  and  in 
ten  of  them  the  attempt  proved  successful  in  showing  that  such 
fragments  retained  their  vitality  and  again  became  a  part  of  the 
bone  during  the  process  of  repair.  Sharp  and  conic  pieces  were 
removed  subperiosteally  with  the  chisel  or  saw,  and  were  either 
reimplanted  in  their  former  position,  or  were  turned  over  before 
reimplantation,  so  that  the  cortical  surface  was  directed  toward  the 
medullary  canal.  After  placing  them  in  position,  the  periosteum 
was  sutured  over  the  fragment,  and  the  wound  having  been  sutured 
and  dressed,  the  limb  was  immobilized.  The  union  of  the  fragment 
with  the  shaft  was  demonstrated  by  stained  vessel  injections,  pro- 
longed feeding  with  madder,  and  microscopic  examination.      The 


DIRECT    FIXATION    OF    FRAGMENTS, 


529 


results  of  von  Bergmann's  experiments  in  the  same  direction  con- 
vinced him  that  the  loose  bone  fragments  from  animals  of  the  same 
species  can  be  successfully  transplanted,  but  if  obtained  from  an- 
other species,  the  experiment  failed. 

The  value  of  autotransplantation  of  bone  is  conceded  by  most 
authorities  of  the  present  time  as  established,  in  operations  upon 
different  kinds  of  animals  as  well  as  upon  man.  That  the  opera- 
tion proves  successful  in  persons  advanced  in  years  as  well  as  in 
children  was  shown  most  conclusively  in  one  of  my  cases.  The 
patient  was  a  man  over  fifty  years  of  age  who  sustained  a  fracture 
of  both  bones  of  the  leg.  The  fibula  united  in  the  usual  length 
of  time  ;  the  fracture  of  the  tibia,  at  the  junction  of  the  middle 
with  the  upper  third, 
failed  to  unite.  Four 
operations  were  per- 
formed for  the  pseud- 
arthrosis,  with  no  re- 
sult. Much  bone  had 
been  lost  by  these 
futile  attempts  to  se- 
cure bony  union,  and 
the  fragments  were 
found  separated  near- 
ly an  inch,  with  abso- 
lutely no  indications 
of  callus  formation. 
The  fractured  sur- 
faces were  vivified 
with  chisel  and  ham- 
mer, and  all  the  frag- 
ments carefully  pre- 
served in  a  warm  nor- 
mal solution  of  salt. 
Large  chips  of  bone 
were  taken  from  the 
anterior     surface    of 

both  fragments,  sufficient  in  number  to  fill  in  the  gap  between  the 
vivified  surfaces  of  the  ends  of  the  fragments.  Periosteum  and  con- 
nective tissue  were  sewed  separately  over  the  loose  pieces  of  bone, 
the  wound  was  closed  throughout  and  sealed,  and  the  limb  was 
immobili/.cd  in  a  plaster-of-Pari.s.  dressing.  Firm  bony  union  took 
place  at  the  end  of  two  months.  The  function  of  the  limb  was  re- 
stored perfectly,  and  the  patient  has  experienced  no  inconvenience 
of  any  kind  since  the  operation,  five  years  ago.  If  such  a  result  is 
possible  in  the  treatment  of  pscudarthrosis,  there  can  be  no  impro- 
l)riety  in  reimplanting  loose  fragments,  in  the  treatment  of  recent 
compound  fractures,  under  strict  antiseptic  precautions.  Every  sur- 
geon is  familiar  with  the  well-established  fact  that  large  fragments  of 
34 


Fig.  326. — Pscudarthrosis  of  the  tibia,  with  extensive 
loss  of  bone  substance,  following  repeated  operation,  a. 
Successful  restoration  of  the  continuity  of  the  bone  by  fill- 
ing in  the  gap  with  bone  chips  from  the  fractured  ends. 


S30 


COMPOUND    FRACTURES. 


bone  can  be  successfully  reimplanted  after  operations  upon  the  skull. 
The  conditions  for  callus  formation  and  bony  union  are  much  more 
unfavorable  here  than  is  the  case  with  the  long  bones.  For  years 
it  has  been  my  practice,  in  opening  the  skull  for  the  purpose  of 
relieving  the  remote  consequences  of  old  fractures,  to  fragment  the 
piece  of  bone  removed  with  chisel  and  hammer  into  chips  of  the 
size  of  the  thumb-nail,  and  smaller,  and  plant  them  upon  the  dura 
in  the  form  of  a  pavement,  and  not  in  a  single  instance  has  any- 
thing been  seen  of  these  loose  fragments  when  the  wound  healed 
by  primary  intention,  which,  with  one  exception,  was  always  the 
case  (see  Figs.  303-307).  The  continuity  of  the  skull  was  invariably 
restored  in  three  or  four  weeks,  which  ought  to 
convince  the  most  skeptical  that  the  fragments 
retained  their  vitality  and  took  an  active  part  in 
the  process  of  repair.  No  surgeon  would,  for  a 
moment,  think  of  removing  the  loose  fragments 
in  a  case  of  comminuted  subcutaneous  fracture, 
because  he  knows,  from  reading  and  observa- 
tion, that  these  fragments  do  no  harm,  and  that 
bony  consolidation  is  the  rule,  regardless  of  the 
extent  of  comminution.  In  recent  compound 
comminuted  fractures  I  recommend  making  a 
faithful  attempt,  under  antiseptic  protection,  to 
preserve  and  reimplant  as  many  of  the  com- 
pletely detached  fragments  as  are  necessary  to 
restore,  as  far  as  possible,  the  normal  length  and 
strength  of  the  bone.  The  temporary  removal, 
separate  disinfection,  and  immersion  in  warm 
saline  solution  prepare  the  pieces  properly  for 
reimplantation.  Fragments  that  are  reimplanted 
must  be  fastened  in  proper  position  by  heavy 
catgut  sutures  or  ligatures.  If  the  space  be- 
tween the  ends  of  the  broken  bone  is  large  and 
the  comminution  extensive,  the  attached  frag- 
ments must  be  handled  with  the  utmost  care 
during  the  disinfection  and  reimplantation  of  the 
loose  fragments  and  their  subsequent  fixation. 
The  reimplantation  must  be  done  in  such  a  manner  that  the  frag- 
ments will  occupy,  as  nearly  as  possible,  their  former  location. 
Drilling  of  the  fragments  must  be  avoided,  as  it  will  complicate  the 
procedure  and  add  little  to  the  security  of  fixation  by  the  ligature 
and  suture.  Different  fragments  can  be  tied  together,  as  well  as  to 
the  ends  of  the  broken  bone.  If  a  firm  support  is  needed,  the  liga- 
ture can  be  made  to  surround  the  parts  it  is  intended  to  unite  three 
or  four  times,  when  it  is  drawn  tight  and  firmly  tied.  Some  of  the 
smaller  fragments  can  be  held  in  place  by  a  suture  including  the 
adjacent  soft  parts.  The  periosteum  must  be  carefully  preserved 
and  utilized  in   covering  the  fragments.     Every  fragment  must  be 


Fig.  327. — Com- 
pound comminuted 
fracture  of  the  fibula  ; 
fragments  fastened  to- 
gether with  catgut 
ligatures. 


DIRECT    FIXATION    OF    FRAGMENTS.  531 

supplied  li'itJi  vascular  tissue  on  all  sides,  and  luJicre  the  periosteum  is 
defective,  the  connective  tissue  and  muscle  must  be  used  to  bury  the 
fragments  by  suturing  liith  catgut.  I  am  satisfied  that  if  this  part 
of  the  treatment  of  recent  compound  fractures  is  more  generally- 
adopted,  excessive  shortening,  delayed  union,  and  pseudarthrosis 
will  figure  less  conspicuously  in  future  statistics  than  they  have 
done  in  the  past.  Should  infection  set  in,  all  these  fragments  are 
removed  during  the  secondary'  disinfection.  If  the  wound  remains 
aseptic,  these  fragments  will  accomplish  much  in  securing  a  speedy 
and  satisfactory  recovery,  and  in  yielding  a  desirable  functional 
result.  If  much  bone  tissue  has  been  lost,  by  either  the  injury  or 
the  subsequent  suppurative  inflammation,  implantation  of  antiseptic 
decalcified  or  aseptic  decalcified  bone  will  render  material  assistance 
in  the  process  of  repair. 

Silver  wire  has  been  extensively  employed  in  the  operative  treat- 
ment of  pseudarthrosis,  and  has  had  a  fair  trial  in  the  direct  fixa- 
tion of  the  fragments  in  recent  compound  fractures.  Lapeyade 
and  Sicre,  of  Toulouse,  are  supposed  to  have  been  the  first  to  use 
silver  wire  for  this  purpose,  in  1775.  The  procedure  appears  to 
have  been  forgotten,  until  it  was  revived  by  Flaubert,  of  Rouen, 
who  was  probably  the  first  one  to  use  the  bone  suture  as  a  means 
of  direct  fixation  in  the  treatment  of  compound  fractures.  He 
used  silk  sutures  in  a  case  of  compound  fracture  of  the  humerus. 
After  the  removal  of  a  large  detached  fragment  of  bone  the  sharp- 
pointed  ends  of  the  bone  were  drilled  obliquely,  when  a  cord  made 
of  four  waxed  silk  ligatures,  twisted,  was  passed  through  the  open- 
ings with  a  needle  and  firmly  tied.  The  end  of  the  lower  frag- 
ment necrosed,  and  the  suture  made  its  escape  from  the  upper 
fragment  in  from  three  to  four  weeks,  but  union  had  commenced 
and  was  subsequently  completed.  Kearney  Rodgers,  of  New  York, 
employed  the  bone  suture  first  in  the  treatment  of  pseudarthrosis 
in  1826.  It  certainly  seems  that  the  time  is  at  hand  when  com- 
pound fractures  presenting  the  indications  for  direct  fixation  should 
be  treated  upon  the  same  principles  as  wounds  of  the  soft  parts — 
viz.,  to  bring  into  apposition  and  hold  in  contact  by  direct  tempo- 
rary mechanical  measures  the  different  anatomic  constituents  of  the 
wound  until  the  process  of  repair  is  completed.  As  soon  as  this 
method  of  treatment  is  perfected  and  more  generally  adopted,  we 
shall  hear  less  frequently  of  the  many  unsatisfactory  remote  results 
of  these  injuries,  such  as  delayed  union  and  pseudarthrosis,  paral- 
ysis, impairment  of  health  from  long  confinement  in  bed,  excessive 
shortening,  angular  deformity,  displacement  by  rotation,  exuberant 
callus,  and  permanent  injury  to  adjacent  joints  from  long-continued 
extension.  In  very  oblique  fractures,  compound  as  well  as  simple, 
intcrpo.sition  of  .soft  ti.ssue  takes  place  more  commonly  than  is 
generally  suppo.sed,  and  this  condition  not  infrequently  is  the  sole 
cause  of  nonunion.  It  is  a  well-known  fact  that  long-continued 
extension  is  fnrtjuently  followed  by  t(ni[)<.rary,  and  occa.sionally  by 


532 


COMPOUND    FRACTURES. 


permanent,  injury  to  the  adjacent  joints.  Overriding  of  fragments 
is  frequently  productive  of  harmful  pressure  upon  important  vessels 
and  nerves.  Displacement  of  fragments  and  imperlect  immobiliza- 
tion are  the  most  potent  influences  in  the  production  of  exuberant 
callus,  which  so  often  impairs  the  functional  result  and  not  infre- 
quently causes  remote  painful  affections.  Displacement  of  detached 
fragments  in  comminuted  compound  fractures  is  often  not  recog- 
nized, and  much  less  frequently  corrected  without  direct  interven- 
tion. Long-continued  confinement  in  bed,  incident  to  treatment  of 
compound  fractures  of  the  lower  extremities,  is  detrimental  to  the 
general  health  of  the  patient,  and  is  often  the  indirect  cause  of 
many  fatal  intercurrent  affections. 

The  evils  attending  the  treatment,  heretofore  in  vogue,  of  com- 
pound fractures  can  be  avoided,  in  a  measure,  by  resorting,  more 
frequently  than  has  been  done,  to  direct  fixation.  Direct  treatment 
of  the  fracture,  in  well-selected  cases,  does  7iot  add  to,  but  rather 
diminishes,  the  danger  of  traumatic  infection,  provided  the  operation 
is  done  with  the  necessary  care  and  under  the  most  pedantic  antiseptic 


Fig.  328. — Old  method  of  bone  suture. 


Fig.  329.  —  Improved  bone  suture. 
Transverse  fracture,  wire  suture  including 
entire  thickness  of  both  fragments. 


precautions.  It  not  only  enables  the  surgeon  to  bring  the  fragments 
into  accurate  apposition  and  secure  permanent  retention,  but  it  also 
makes  it  possible  for  him  to  disinfect  every  part  of  the  wound  and 
to  arrest  the  hemorrhage,  important  elements  in  the  prevention  of 
traumatic  infection.  Moreover,  it  at  the  same  time  materially  simp- 
lifies the  immobilization  of  the  fractured  bone  by  an  external  me- 
chanical support.  Such  treatment,  thoroughly  and  conscientiously 
instituted,  imparts  a  sense  of  security  regarding  the  usual  immediate 
and  remote  complications  that  is  foreign  to  the  ordinary  routine 
treatment. 

The  oldest  method  of  accomplishing  direct  fixation  is  by  suture 
or  ligature.  Different  kinds  of  metallic  wire,  silk,  silkworm-gut, 
and,  more  recently,  absorbable  sutures  have  been  employed.  Silver 
wire  is  the  material  most  frequently  used,  owing  to  its  nonirritating 
nature  and  the  ease  with  which  it  becomes  encapsulated  in  the  tis- 
sues. Before  antiseptic  surgery  was  practised  the  ends  of  the  wire 
were  brought  out  of  the  wound,  with  the  intention  of  removing  the 
suture  as  soon  as  the  object  for  which  it  was  employed  was  real- 
ized.     Since  it  has  been  ascertained,  by  experiments  and  clinical 


DIRECT    FIXATION    OF    FRAGMENTS. 


533 


observation,  that  small  aseptic  bodies  can  be  safely  left  in  aseptic 
wounds,  the  wire  was  cut  short  to  the  twist,  with  the  expectation 
that  the  suture  would  become  encysted  and  remain  indefinitely  in 
the  tissues  without  causing  any  disturbance.  In  the  treatment  of 
compound  fractures  by  direct  means  of  fixation  the  silver-wire 
suture  is  most  applicable  and  efficient  when  the  fracture  is  com- 
minuted and  there  is  little  tendency  to  longitudinal  displacement. 
In  oblique  fractures  with  a  tendency  to  excessiv^e  shortening,  the 
tension  on  the  suture  is  great,  and  undoubtedly  has  often  seriously 
impaired  the  nutrition  of  the  part  of  the  fragments  included  in  the 
suture.  For  good  reasons  the  bone  suture  has  often  been  charged 
with  causing  necrosis.  The  old  method  of  suturing  fragments  is 
very  defective,  as  the  suture  was  made  to  include  only  one  side  of 
the  broken  bone. 

The  technic  of  bone  suture  has  recently  been  materially  im- 
proved.    Wille,  of  Denmark,  uses  a  drill  with  an  eye  near  the  point 


Fig.   330. — Oblique  fracture   sutured.        Fig.  331. — Extent  of  lateral  and  longitu- 
showing  curve  in  which  fragment  will  be-  dinal  displacement  that  may  occur, 

come  displaced. 

for  the  wire,  which  is  carried  with  the  instrument  through  the  per- 
forations, thus  greatly  facilitating  the  insertion  of  the  suture,  which 
formerly  often  con.stituted  a  tedious  task.  He  has  modified  the  old 
method  in  so  far  that  the  wire  is  made  to  include  the  entire  thick- 
ness of  the  bone  on  both  sides  in  wiring  transverse  and  slightly 
oblique  fractures.  The  wire  is  always  cut  short  to  the  twist,  and 
the  twisted  portion  is  bent  down  and  buried  through  a  small  tear  or 
incision  in  the  periosteum,  so  that  the  suture  is  subperiosteal.  The 
same  author  has  also  shown  that,  in  suturing  oblique  fractures  by 
this  method,  the  suture  docs  not  prevent  lateral  and  longitudinal 
di.splaccment,  as  can  be  .seen  from  the  two  accompanying  illustra- 
tions (Figs.  330  and  331).  The  further  the  drill  openings  are  apart, 
the  greater  will  be  the  tendency  to  displacement.  In  very  oblique 
fractures  Wille  advises  the  cutting  of  two  grooves,  with  a  file  or  .saw, 
in  the  fragments,  the  direction  of  the  grooves  being  at  a  right  angle 
to  the  fractured  surfaces,  and  tying  the  fragments  firmly  together 


534 


COMPOUND    FRACTURES. 


with  the  silver  wire.  If  the  seat  of  fracture  is  sufficiently  accessi- 
ble so  that  the  drill  can  be  applied  vertically  to  the  fractured  sur- 
faces, he  drills  through  both  fragments,  and,  with  a  hook  of  his  own 
device,  pulls  a  loop  of  silver  wire  through  the  perforation,  cuts  the 
wire  in  the  center,  and  twists  each  half  separately.  It  appears  to 
me  that  in  operating  by  this  method  it  would  be  much  better  not 
to  cut  the  wire,  but  to  pass  both  ends  through  the  loop  and  twist 
them  in  the  same  manner  as  in  tying  the  Staffordshire  knot. 

Dollinger  describes  a  new  method   of  bone   suture,   or   rather 
bone  ligation,  which  he  has  employed  in  several  cases  where  per- 


Fig.  332. — Peripheral  groove  for  wire.  Fig.  ^^;^. — Lateral  groove  for  wire. 


I^ig-  334- — Wire  drawn  through  the 
perforation. 


Fig.  335. — Wire  cut  in  the  center  and 
each  half  twisted  separately. 


Fig-  336. — Senn's  modification  of  twisting 
the  wire  (Staffordshire  knot). 


■^'g-  337- — Bollinger's  bone  ligation  as  a 
substitute  for  bone  suture. 


foration  of  the  bone  could  not  easily  be  carried  out.  In  one  case 
--pseudarthrosis  of  the  leg  in  a  man  forty-three  years  old — the 
tibia  was  sutured  in  the  usual  manner.  The  fibula  was  fractured  in 
two  places,  the  middle  piece,  about  four  inches  in  length,  lying 
loose.  The  fragments  could  not  be  perforated  without  causing 
further  separation  of  the  periosteum.  A  ring  of  silver  wire  was 
placed  around  the  lower  part  of  the  upper  fragment,  a  little  above 
the  seat  of  fracture,  and  a  similar  ring  around  the  upper  part  of  the 
middle  fragment.  A  piece  of  wire  was  then  placed  on  each  side 
of  the  fragments,  parallel  to  the  long  axis  of  the  bone  and  within 


METALLIC    SPIKES,    SCREWS,    NAILS,    AND    CLAMPS.  535 

the  two  rings  encircling  the  bone.  The  rings  were  then  tightened 
up  and  fixed,  and  the  longitudinal  wires  doubled  over  and  their 
ends  united  on  each  side.  The  second  fracture  was  dealt  with  in  a 
similar  manner.  In  eight  weeks  union  by  bony  callus  had  taken 
place.  In  another  case  the  tibia  was  sutured  in  like  fashion 
after  a  piece  had  been  resected,  together  with  a  tumor  that  had 
developed  in  the  part.  The  resected  ends  were  hard  and  ivory- 
like, and  could  not  readily  be  sutured  in  the  ordinary  way. 

While  this  method  of  suturing  may  guard  effectively  against 
diastasis  of  the  fragments,  it  certainly  could  not  prevent  lateral 
displacement  and  shortening  in  oblique  fractures,  and  consequently 
the  indications  for  its  employment  are  very  limited.  Bone  is  very 
tolerant  to  the  presence  of  silver  wire,  and  if  the  wound  remains 
aseptic,  permanent  encapsulation  of  the  suture  is  the  rule.  The 
modifications  of  suturing  the  fragments,  as  described,  are  a  great 
improvement  upon  the  old  method,  but  do  not  set  aside  all  the 
objections  to  the  silver-wire  suture  in  securing  direct  fixation.  The 
drilling  of  the  fragments,  the  passing  of  the  wire  through  the  per- 
foration made  with  the  drill,  the  twisting  of  the  wire,  are  details 
that  often  require  a  great  deal  of  time  and  are  frequently  attended 
by  many  difficulties.  At  the  same  time  the  necessary  degree 
of  immobilization  is  not  attained  without  ex- 
posing the  bone  to  harmful  linear  compression 
if  the  fracture  is  very  oblique.  While  such 
means  of  direct  fixation  may  frequently  an- 
swer a  useful  purpose  in  the  treatment  of  un- 
united fractures,  they  are  not  applicable  in 
maintaining  retention  in  very  oblique  recent  y-       ,,8— Bmns' 

fractures,    owing    to    the    strong    muscular     double  metallic  nail  for 
contractions   invariably   encountered  in    such      fixation  of  fragments. 
cases. 

Metallic  Spikes,  Screws,  Nails,  and  Clamps. — Among  the 
older  methods  of  direct  immobilization  of  compound  and  ununited 
fractures  must  be  mentioned  the  sharp  metallic  spikes  recommended 
by  Malgaigne,  and  used  quite  extensively  in  the  treatment  of 
oblique  fractures  of  the  tibia.  By  screw  action  the  spike  makes 
direct  pressure  against  the  displaced  fragment.  Dieffenbach  trans- 
fixed the  fragments  with  an  iron  nail,  and  applied  over  it,  including 
one  side  of  the  fragments,  a  figure-of-eight  suture.  MacCormac 
u.sed  two  strong  steel  needles  for  the  transfixion  of  the  fragments, 
in  combination  with  the  figure-of-eight  suture.  The  employment 
of  aseptic  bone  or  ivory  nails  for  the  same  purpose  presents  the 
great  advantage  over  the  metallic  nails  that  the  material  used  is 
ahsf>rbable  and  does  not  require  removal,  thus  diminishing  the 
danger  from  po.stoperative  infection,  and  placing  the  wound  in  a 
condition  for  primary  healing  throughout. 

Langenbeck's,  Parkhill's,  and  Marks'  bone  clamps  are  ingenious 
devices,  and  may  be  used  in  well-selected  cases  to  advantage,  but 


536 


COMPOUND    FRACTURES. 


the  same  objections  hold  good  against  their  general  use  that  have 

been  made  against  the  metalhc  nails  and  spikes. 

Langenbeck  used  two  steel  screws,  which  were  driven  into  the 

fragments   and  were  then  connected 
■A-  by  an  iron  bar,  which  effected  im- 

mobilization of  the  fragments. 

Ivory  Cylinders  and  Clamps. — 
Volkmann  and  Heine  inserted  into 
the  medullary  cavity  of  the  frag- 
ments ivory  cylinders  across  the 
line  of  fracture,  with  a  view  of  pre- 
venting lateral  and  longitudinal  dis- 
placement. This  method  of  treat- 
ment has  been  more  fully  described 
by  Bircher,  to  whom  it  has  gener- 
ally been  accredited.  Bircher  used 
a  solid  ivory  cylinder.      Its  method 

of  insertion  and  relative  position   to  the  fragments  are  shown  in 

figure  340. 

To  prevent  slipping  of  the  ivory  cylinder  upward  or  downward, 

he  makes  a  shoulder  or  projection  at  the  center  on  one  side  of  the 


Fig.  339. — Nails  for  fixation  of 
fragments :  A,  Ivory  nail  ;  B,  horse- 
shoe nail ;  C,  Gerster's  metallic  nail. 


Fig.  340.— Bircher' s  method  of  retention  with  ivory  cylinder  :  a,  Direction  of  pres- 
sure, traction  upon  leg  ;  b,  fragments  and  cylinder  in  position  (longitudinal  section  ;  natural 
size)  ;  c,  transverse  section,  showing  ivory  cylinder  in  the  interior  of  the  medullary  canal. 

cylinder,  which  rests  in  a  depression  made  with  a  chisel  in  one  side 
of  the  medullary  canal,  as  is  shown  in  figure  341,  or  in  a  bone 
defect  at  the  seat  of  fracture,  as  in  figure  342. 


IVORY    CYLINDERS    AND    CLAMPS. 


537 


The  ivon'-  clamp  that  he  uses  in  uniting  fractures  of  parts  of 
bones  devoid  of  a  medullary  cavity  resembles  the  capital  letter  H, 
one  bar  of  which  rests  in  the  channels  cut  on  each  side  in  the 
bone,  while  the  other  bar 
rests  on  the  surface  of  the 
fragments  (Fig.  343). 

Bircher  treated  five 
cases  by  these  methods 
of  fixation,  four  compound 
fractures  and  one  subcu- 
taneous fracture  (femur) 
complicated  by  a  large 
hematoma.  In  all  the  cases  more  or  less  suppuration  followed, 
and  the  foreign   body  was  removed  as  soon  as  firm  consolidation 


Fig.  341.  —  Shoulder  of  ivory  cylinder  fixed  in  de- 
pression of  wall  made  with  chisel. 


Fig.  342. — Projection  resting  in  defect  at  seat  of  fracture. 

had  taken  place.      In  every  instance  bony  union  in  good  po.sition 
with  very  little  shortening  was  secured,  and  the  functional  results 

were  excellent.  In  the  compound 
fractures  infection  had  taken  place 
before  the  treatment  was  commenced. 
Socin  has  given  this  method  of 
treatment  an  extensive  trial,  and  is 
pleased  with  the  results.  He  has 
u.sed  it  in  pseudarthrosis  caused  by 
defective  reposition  or  interposition 
of  soft  parts,  and  in  many  cases  of 
compound  fracture.  He  does  not 
resort  to  the  operative  removal  of 
the  cylinder.  The  method  has  proved 
so  satisfactory  in  his  hands  that  he 
intended  to  extend  it  to  the  treat- 
ment of  subcutaneous  fractures  with 
a  strong  tendency  to  displacement  of 
the  fragments,  as  in  very  oblicjue  fiac- 
tures  of  the  lower  third  of  the  tibia. 
The  method  is,  of  course,  inapplicable 
to  fractures  with  comminution.  The 
size  of  Bircher's  cylinder  is  a  serious 
objection,  as  the  introduction  of  so  large  and  solid  a  mass  of  ivory 


Fig.  343. — Reteiitif>n  of  ob- 
lique fracture  of  lower  end  of  tibia 
by  ivory  clamp. 


53« 


COMPOUND    FRACTURES. 


Fig.  344. — Senn's  hollow  perforated  intra- 
osseous splint. 


overtaxes  the  absorptive  capacity  of  the  tissues,  and  removal 
by  operative  treatment  becomes  necessary,  or  spontaneous  expul- 
sion is  almost  sure  to  take  place  sooner  or  later.  There  is  a  hmit 
to  the  absorption  of  aseptic  absorbable  substances.  While  aseptic 
ivory  or  bone  nails  driven  into  bone  for  the  purpose  of  exciting 

callus  formation  or  to  serve  as  a 
temporary  means  of  fixation  will 
be  removed  by  absorption  in  the 
course  of  time,  if  their  immedi- 
ate vicinity  remains  aseptic,  a 
similar  disposal  of  a  solid  ivory 
cylinder  the  thickness  of  the 
little  finger  could  hardly  be 
expected.  Gluck's  experiments 
with  ivory  joints  have  taught  us  an  important  lesson,  and  that  is 
not  to  impose  too  much  upon  the  intrinsic  absorptive  power  of  the 
tissues.  Of  one  thing  we  are  now  certain,  that  the  diminution  in 
size  and  the  ultimate  removal  of  such  bodies  are  not  brought  about 
by  the  corroding  action  of  pus,  as  has  been  claimed  by  many,  but 
by  the  action  of  living  tissues. 

The  mechanical  effect  is  the  same,  whether  a  solid  or  a  hollow 
cylinder  of  ivory  or  bone  is  used.  For  this  reason  I  recommended, 
a  number  of  years  ago,  the  employment  of  absorbable  hollow, 
perforated  cylinders  of  bone  as  intra-osseous  splints.  The  use 
of  such  cylinders  does  not  interfere  with  the  early  formation  of 
the  intermediate  callus  from  the  medullary  tissue,  a  tissue  so 
important  in  effecting  the  final  bony  union  between  the  frag- 
ments. Instead  of  crushing  the  medullary  tissue,  as  is  done  by 
the  use  of  the  solid  cylinder,  the  lumen  of  the  hollow  cylinder  is 
filled  at  once  with  this  valuable  bone-producing  material  and  the 
product  of  tissue  proliferation,  and  the  new  blood-vessels  later  fill 
the  perforations,  establishing  a  communication  between  the  pro- 
cess of  repair  within  and  outside  of  the  cylinder.  The  surface  for 
absorption  of  the  foreign  substance  is  also  immensely  extended, 
and  thereby  the  probability  of  its 
spontaneous  removal  greatly  in- 
creased. Such  cylinders  should 
be  made  of  the  shaft  of  the  long 
bones  of  young  animals,  such  as 
chickens,  turkeys,  or  rabbits.  The 
medullary  cavity  can  be  increased 
in  size  and  the  compacta  reduced  in  thickness  by  the  use  of  a  round 
file,  and  the  lateral  perforations  may  be  made  with  a  drill.  Fenes- 
tration of  the  tube  is  an  important  part  of  its  proper  construction, 
as  new  bone  tissue  and  blood-vessels  can  then  reach,  at  an  early 
stage  during  the  process  of  repair,  the  interior  of  the  tube  from  the 
adjacent  bone-walls.  The  length  of  this  intra-osseous  splint  will 
vary,  according  to  the  size  of  the  bone  and  the  obliquity  of  the  frac- 


Fig.  345. — Appearance  of  ivory  nail 
used  in  the  fixation  of  an  ununited  frac- 
ture of  the  femur  seven  vi^eeks  after  the 
operation.      Profuse  suppuration  (Bruns). 


IVORY    CYLINDERS    AND    CLAMPS. 


539 


tare   from  one  to  three  inches.      Displacement  of  the  sphnt  upwaid 
or  do^vn^vard  need  not  be  feared  if  additionaUmmobihza  ion  is  se- 
cured bv  an  appropriate  external  support.      Experimental  research 
and   clii^cal   experience   have   demonstrated  that  pieces  of  aseptic 
i\-oiy  or  bone  of  moderate  size  are 
removed   slowly  b)-  absorption   in 
aseptic  tissues,  a  task  accomplished 
largely    by    the    agency    of    giant 
cells.    Riedinger  made  experiments 
on  animals  in  reference  to  the  fate 
of  ivory  nails,  fragments  ot  bone, 
and  other  material  implanted  into 
living  bone.     Wood,   rubber,  etc., 
in    every    instance    produced    sup- 
puration and  were  invariably  elim- 
inated.     Ivory    and     fragments    of 
bone,  even  if  taken  from  another 
species    of    animal,    produced    no 
such    result,    and    were    gradually 
reduced  in  size  and  eventually  dis- 
appeared by  absorption.     He  made 
the  observation  that  the  speed  with 
which  the  material  disappeared  by 
absorption  depended  largely  on  the 
degree  of  vascularity  of  the  bone. 
Intone  experiment  a  fragment    of 
bone   that  was  driven   into  a  per- 
foration of  the  shaft  of  a  long  bone 
did  not  undergo  absorption,  except 

that  part  which  projected  into  the  . 

medunarv  cavitv.      He  ascertained,  also,  by  his  experiments  tha 
vor>  or  bone  pegs  driven  into  the  shaft  of  along  bone  bi^ugh 
about  elongation  of  the  bone.      Two  ivory  nails  inserted    nto  the 
kf"l^  of  a  dog  increased  the  length  of  the  bone   our  millm.eters^ 
^SMa;   observafions  w.re  made   by  Aufrecht  ancl jhe^aut^^^^^^^^ 

tal  work  on  the 
same  subject. 
Experiments  and 
observations 
made  so  far  prove 
conclusively  that 
bone  or  ivory 
nails  and  hollow 
cylinders  used  in 


Pig  346.— Section  through  par- 
tially absorbed  ivory  nail.  The  mar- 
gins of  the  ivory  (e)  consist  of  lacunK, 
the  margins  of  which  appear  serrated. 
( )n  the  left  margin  giant  cells  (r)  can  be 
seen  in  some  of  the  lacuna  (after  Bid- 
der). 


Fig.  347. — Intra-osseous  splint  in  situ. 


the  direct  fixation  of  a  fracture  can  safely  be  left  in  the    issues      th 
he  expectation  that  the  material  will  become  te-Poranly  enc>  sted 
and  remain   harmless,  and  that  in  the  course  of  time  it  will  be  re 


540 


COMPOUND    FRACTURES. 


moved  by  absorption.  They  teach  also  that  these  substances  are 
more  rapidly  removed  by  absorption  when  inserted  into  the  medul- 
lary cavity,  or  when  placed  around,  instead  of  into,  the  bone.  My 
own  experience  has  shown,  to  my  own  satisfaction,  that  bone  is 
absorbed  more  readily  and  in  a  shorter  time  than  ivory,  and  on  this 
account  the  former  material  should  have  the  preference  in  the  direct 
treatment  of  fractures.  Ample  experience  has  demonstrated  that 
a  hollow  cylinder  of  bone  inserted  into  the  medullary  cavity  is  re- 
moved completely  by  absorption  in  the  course  of  two  or  three 
months.  The  same  disposition  is  made  of  a  thin  ring  of  bone, 
embracing  and  holding  in  mutual  uninterrupted  contact  two  or 
more  fragments,  in  the  treatment  of  compound  and  ununited  frac- 
tures by  direct  fixation. 

Fixation  of  Fragments  with  Bone  Ferrule. — The  most  efficient 
way  to  prevent  lateral  and  longitudinal  displacement  in  oblique 
fractures  of  the  shaft  of  the  long  bones  is  to  bring  the  fractured 
surfaces  in  accurate  contact,  and  to  hold  them  in  this  position  by 
an  efficient  absorbable  circular  support.  The  use  of  the  silver  wire 
and  other  unabsorbable  suture  material  for  this  purpose  is  objection- 
able, because  the  linear  pressure  caused  by  the  support  must  affect 
the  fragments  in  a  detrimental  manner,  and  the  circular  splint, 
even  if  it  become  encysted,  remains  as  a  foreign  body,  liable  at 
any  time  to  become  a  source  of  irritation  and  remote  complications. 
Catgut  and  other  absorbable  ligatures  in  many  cases  are  not  suffi- 
ciently durable  to  hold  the  parts  in  contact  for  a  sufficient  length 
of  time.  It  has  occurred  to  me  that  such  fractures  could  be 
retained  almost  to  perfection  after  reduction  by  engaging  the  ends 
of  the  fragments  in  a  ferrule  or  ring  of  ivory  or  bone.  The  rough, 
and  often  denticulated,  fractured  surfaces,  held  in  contact  by  the 
temporary  circular  splint,  will  bring  about  interlocking  of  the  frag- 
ments, the  best  safeguard  against  undue  shortening.  If  the  fractured 
surfaces  are  smooth  and  interlocking  of  the  fragments  can  not  thus 
be  secured,  shortening  and  lateral  displacement  are  effectually  pre- 
vented by  the  ring.  The  broken  ends  grasped  by  the  ring  act  in 
the  manner  of  two  inclined  planes  gliding  in  opposite  directions, 
which  will  permit  sliding  of  one  fragment  over  the  other  only  until 
each  fragment  impinges  against  the  respective  side  of  the  ring,  after 
which  further  overriding  is  a  mechanical  impossibility.  Angular 
deformity  and  rotation  can  readily  be  prevented  by  an  appropriate 
external  support.  The  application  of  such  a  bone  or  ivory  ferrule 
requires  less  time,  is  attended  by  slighter  disturbance  of  the  soft  parts, 
and  is  a  much  easier  procedure  than  suturing  of  the  bone.  In  my 
experience  the  results  that  have  so  far  attended  this  method  of 
treating  compound  fractures  have  been  exceedingly  satisfactory, 
and  have  induced  me  to  again  present  this  method  of  direct  fixa- 
tion to  the  attention  of  the  profession  for  a  thorough  trial. 

The  ferrules  are  made  of  different  sizes,  from  fresh  bone 
obtained    from    the    slaughter-house    or    butcher-shop.      For    the 


FIXATION    OF    FRAGMENTS    WITH    BONE    FERRULE. 


541 


humerus  and  femur  of  the  adult  the  femur  of  an  ox  should  be 
selected ;  for  children  the  same  bone  of  a  smaller  animal  will 
answer  the  purpose.  For  the  tibia  the  corresponding  bone  of  the 
animal  is  chosen.  With  a  sharp  saw  the  shaft  of  the  bone  is  cut 
transversel}^,  the  length  of  the  sections  corresponding  with  the 
desired  width  of  the  ferrule,  which  will  vary  from  one-fourth  of  an 
inch  to  an  inch.  With  a  round  file  the  medullary  canal  is  enlarged 
until  the  thickness  of  the  bone  does  not  exceed  one-sixth  of  an 
inch  ;  in  some  instances  a  much  thinner  ring  will  furnish  the 
necessary  lateral  support.  If  the  ferrule  is  longer  than  an  inch,  it 
should  be  perforated  at  a  number  of  points,  in  order  to  furnish 
avenues  through  which  the  products  of  tissue  proliferation  and  the 
new  blood-vessels  can  reach  the  tissues  in  both  directions,  and  also 
with  the  intention  of  facilitating  the  absorption  of  bone  after  the 
fracture  has  become  consolidated.  Ferrules  made  of  the  tibia 
should  retain  the  shape  of  the  bone,  in  order  to  adapt  their  lumen 
to  the  treatment  of  fractures  of  the  tibia.     Sterilization  is  effected 


Fig.  348. — Bone  ferrules  for  immobilizing  fractures  :  a.  Circular  bone  ferrule  for 
humerus  or  femur,  made  of  an  ox  femur ;  b,  triangular  bone  ferrule  for  tibia,  made  of 
ox  tibia  ;  r,  wide  perforated  circular  bone  ferrule. 

by  boiling,  for  an  hour  or  more,  in  soda  solution,  after  which  the 
rings  are  kept  immersed  in  sublimate  alcohol,  i  :  looo,  ready  for 
u.se.  Partial  decalcification  of  the  bone  ferrule  is  an  advantage. 
Should  further  clinical  experience  show  that  the  bone  is  not  suffi- 
ciently absorbable,  such  ferrules  could  be  made  of  chromicized 
catgut  or  partially  decalcified  bone. 

In  the  treatment  of  compound  fractures  the  observance  of  the 
.strictest  antiseptic  precautions,  and  in  the  operative  treatment  of 
pseudarthrosis  by  this  method,  rigid  aseptic  measures,  must 
precede  and  accompany  the  direct  treatment  of  fractures.  The 
seat  of  fracture  must  be  exposed  in  such  a  way  that  both  fragments 
are  readily  accessible.  The  ferrule  mu.st  be  large  enough  so  that 
it  can  be  slipped  over  the  fragments  without  danger  of  breaking  it. 
In  tile  majority  of  ca.ses  the  use  of  a  general  anesthetic  is  indispen- 
sable for  the  purpose  of  securing  complete  muscular  relaxation  and 
the  nece-s.sary  immobility  of  the  limb,  not  only  until  reduction  is 
effected  and  the  ferrule  is  in  place,  but  until  the  whole  dressing  is 
applied  and  complete  immobility  at  the  seat  of  fracture  has  been 


542 


COMPOUND    FRACTURES. 


Fig.  349. — Oblique  fracture  of 
femur  united  by  bone  ferrule. 


secured  by  a  proper  external  mechanical  support.      After  the  seat 

of  fracture  has  been  freely  exposed,  the 
most  accessible  fragment  is  isolated  from 
the  surrounding  tissues  with  as  little  dis- 
turbance of  the  periosteum  as  possible, 
when  the  ferrule  is  slipped  over  the  frag- 
ment and  pushed  away  from  the  line  of 
fracture  far  enough  to  clear  the  other 
fragment.  After  reduction  has  been  ac- 
complished, the  second  fragment  is  en- 
gaged in  the  ring,  which  is  then  pushed 
back  sufficiently  to  grasp  both  fragments 
securely.  A  reliable  assistant  should  hold 
the  limb  securely  in  position,  as  bending 
at  the  seat  of  fracture  might  break  the 
ring.  Hemorrhage  is  to  be  carefully 
arrested,  and  if  the  wound  is  aseptic,  the 
different  tissues  are  separately  united  by 
buxied  sutures.  In  case  of  infected  frac- 
tures and  in  fractures  accompanied  by 
troublesome  oozing,  free  drainage  must 
be  established.  Bending  at  the  seat  of 
fracture  is  prevented,  and  absolute  immo- 
bilization secured,  by  a  circular  plaster-of- 
Paris  dressing  or  plastic  splints.  Harmful  pressure  is  avoided  by 
interposing  between  the  surfaces  of  the  limb 
and  splint  a  layer  of  antiseptic  hygroscopic 
cotton,  at  least  an  inch  in  thickness,  and 
localized  decubitus  is  prevented  by  protect- 
ing all  bony  subcutaneous  prominences  with 
special  care.  With  a  view  of  securing  per- 
fect immobility  of  the  fragments  as  early  as 
possible,  small  splints  of  wood  or  metal  are 
incorporated  in  the  plaster-of-Paris  splint  in 
such  a  way  as  to  form  an  unyielding  bridge 
across  the  line  of  fracture,  an  important  matter 
during  the  time  required  for  the  setting  of  the 
plaster.  The  limb,  especially  if  it  is  the  lower 
extremity,  should  be  kept  suspended  in  an  ele- 
vated position  for  a  number  of  days,  in  order  to 
prevent,  as  far  as  possible,  the  occurrence  of 
edema  at  and  below  the  seat  of  fracture.  If 
the  wound  has  not  been  drained  and  no  indica- 
tions for  a  change  of  dressing  present  them- 
selves, the  first  dressing  should  not  be  dis- 
turbed until  union  between  the  fragments  is 
sufficiently  firm  to  prevent  displacement  during 
the  second  dressing.      In  wounds  that  require  drainage  the  dressino- 


F'g-  350— Trans- 
verse fracture  of  hu- 
merus immobilized  by 
a  wide  perforated  bone 
ferrule. 


FIXATION    OF    FRAGMENTS    WITH    BONE    FERRULE.  543 

is  changed  after  from  two  to  five  days,  without  disturbing  the 
fixation  sphnt.  Should  suppuration  set  in,  the  bone  ferrule  should 
not  be  removed  until  direct  fixation  has  become  unnecessary,  when 
the  sinus  is  enlarged,  the  ring  cut  on  one  side  with  bone  forceps, 
and  fractured  on  the  opposite  side  by  bending,  when  each  half  can 
be  extracted  separately.  Loose  fragments  of  bone,  should  they  be 
present,  are  removed  at  the  same  time. 

In  comminuted  fractures  two  rings  may  be  employed  with 
advantage,  and,  if  need  be,  some  of  the  smaller  fragments  between 
them  can  be  held  in  proper  position  b}-  catgut  ligatures  or  sutures. 
All  methods  of  direct  fixation  have  in  view  the  bringing  and  hold- 
ing in  contact  of  the  fractured  surfaces  as  accurately  as  possible, 
for  the  purpose  of  taxing  the  regenerative  powers  to  a  minimum, 
and  to  obtain  union  by  bony  callus  with  as  little  lateral  and  longi- 
tudinal displacement  as  is  compatible  with  the  nature  of  the  injury. 

Fixation  Dressing. — Immobilization  of  the  fractured  bone  by 
any  of  the  methods  of  direct  fixation  can  not  be  relied  upon  exclu- 
sively in  securing  for  the  seat  of  injury  the  requisite  degree  of  rest, 


Fig.  351. — Compound  oblique  fracture  of  tibia  treated  by  direct  fixation  of  fragments 
and  application  of  fenestrated  plaster-of- Paris  splint. 

and  in  preventing  more  or  less  displacement  of  the  fragments  dur- 
ing the  process  of  healing.  For  these  reasons  direct  fixation  should 
always  be  supplemented  by  some  reliable  external  support.  The 
immobilization  of  a  compound  fracture,  with  or  without  a  recourse 
to  direct  fixation,  always  presents  greater  difficulties  than  the 
mechanical  fixation  of  a  subcutaneous  fracture  of  the  same  bone 
and  in  the  same  locality.  The  swelling  following  a  compound 
fracture  is  usually  more  extensive  than  after  a  simple  fracture,  and 
calls  for  additional  precautions  in  guarding  against  harmful  pres- 
sure on  the  part  of  the  mechanical  means  that  are  employed  to 
immobilize  the  fracture.  The  wound  and  the  dressing  present  dif- 
ficulties in  the  application  of  an  external  mechanical  support  that 
often  tax  the  ingenuity  of  the  surgeon  to  the  utmost  extent  in  over- 
coming them  without  impairing  the  efficiency  and  reliability  of  the 
mechanical  treatment.  One  of  the  most  important  indications  in 
the  treatment  of  a  compound  fracture,  after  the  wound  has  received 
proper  attention,  is  to  apply  an  external  fixation  dressing  that  will 
make  allowance  for  the  subsequent  swelling,  and  that  need  not  be 
disturbed  in  gaining  access  to  and  in  inspecting  and  redressing  the 


544 


COMPOUND    FRACTURES. 


wound.  At  the  time  the  first  dressing  is  appHed  it  is  impossible  to 
predict  whether  or  not  the  wound  will  suppurate,  and  the  mechani- 
cal treatment  must  be  such  as  to  anticipate  all  the  compHcations 
that  might  arise  from  wound  infection.  In  recent  fractures  we  are  not 
in  a  position,  even  in  the  simplest  forms  and  after  a  most  thorough 
primary  disinfection,  to  say  positively  that  the  wound  is  aseptic,  and 
we  must  be  governed  accordingly  in  the  treatment  of  the  fracture. 
While  the  obstacles  encountered  in  securing  rest  and  correct  posi- 
tion for  the  fractured  bone  in  recent  cases  are  many,  the  difficulties 
are  multiplied  manifold  in  the  treatment  of  a  suppurating  com- 
pound fracture.  In  such  event  the  wound  must  be  exposed  at 
short  intervals  or  permanently,  and  this  should  be  made  possible 
without  disturbing  the  fixation  dressing.  Under  such  circum- 
stances no  fixed  rules  can  be  laid  down  to  guide  the  surgeon 
in  efforts  to  maintain  retention. 

Much  stress  has  been  placed  on  the  importance  of  the  buried 
sutures  in  providing  a  vascular  cover  for  the  fragments  in  the  treat- 
ment of  open  wounds  complicating  a  fracture,  in  order  to  secure 
for  partially  and  completely  detached  fragments  a  free  vascular 
supply,  and  for  the  purpose  of  placing  the  soft  tissues  in  the  most 
favorable  condition  for  satisfactory  healing  by  primary  intention. 
The  same  careful  attention  must  be  given  the  fractured  bone.  Every 
movement  at  the  seat  of  fracture  disturbs  the  relations  of  the  frag- 
ments and  affects  unfavorably  the  adjacent  soft  tissues,  thus  inter- 
fering seriously  with  the  healing  of  the  wound  and  the  repair  of  the 
fracture.  Unrest  at  the  seat  of  fracture  inflicts  additional  injuiy  on 
the  damaged  medullary  tissue,  and  frequently  results  in  displace- 
ment of  partially  detached  or  isolated  fragments  from  the  places  in 
which  they  were  brought  when  the  fracture  was  reduced,  and  where 
they  belong  in  effecting  a  satisfactory  repair  of  the  fracture.  The 
first  thing  to  be  done  in  procuring  rest  for  the  fracture  is  to  place  the 
limb  in  proper  position.  Muscular  attachments  must  be  considered, 
and  their  action  on  the  fragments  must  be  carefully  studied.  A 
disregard  of  this  part  of  the  treatment  is  often  the  direct  cause  of 
displacements  that  can  not  be  corrected  by  any  external  appliance. 
In  fractures  of  the  shaft  of  the  femur  between  the  trochanter  minor 
and  the  junction  of  the  upper  with  the  middle  third,  if  the  limb  is 
dressed  in  a  straight  position,  nothing  can  prevent  the  upper  frag- 
ment from  tilting  forward  and  outward,  and  if  the  fracture  unites, 
it  does  so  with  marked  angularity  and  considerable  shortening  of 
the  limb.  A  fracture  in  this  locality  must  be  treated  by  immobiliz- 
ing the  thigh  at  an  angle  of  at  least  45  degrees,  and  extension 
must  be  made  with  the  axis  of  the  femur  in  a  direction  downward, 
forward,  and  outward,  to  correspond  with  the  axis  of  the  upper 
fragment.  This  is  accomplished  most  satisfactorily  by  placing  the 
limb  upon  a  double  inclined  plane,  and  by  making  extension  on  the 
thigh  by  weight  and  pulley. 

In  fractures  of  both  bones  of  the  leg  great  lateral  and  longi- 


FIXATION    DRESSING.  545 

tudinal  displacement  can  often  be  more  effectually  prevented  by- 
relaxing  the  flexor  muscles  by  placing  the  limb  in  Pott's  position 
than  by  any  kind  of  dressing  with  the  limb  in  a  straight  position. 
After  paying  due  attention  to  position  in  securing  relaxation  of 
powerful  muscles,  if  any  marked  tendency  to  shortening  of  the  limb 
remains,  this  must  be  counteracted  by  making  continuous  extension, 
usually  by  weight  and  pulley.  In  fractures  of  the  thigh  in  the 
upper  third  the  extension  is  made  at  an  angle  of  45  degrees,  with 
the  leg  flexed.  In  fractures  of  the  remaining  portion  of  the  shaft 
of  the  femur  extension  with  the  limb  in  a  straight  position  usually 
gives  the  best  results.  In  the  latter  case  the  strips  of  adhesive 
plaster  should  be  made  to  reach  near  the  base  of  the  thigh,  as  by 
making  the  extension  below  the  knee-joint  for  any  length  of  time, 
and  with  sufficient  force  to  prevent  undue  shortening,  the  ligaments 
are  not  infrequently  damaged  sufficiently  to  impair  the  function  of 
the  joint  for  a  long  time,  and  occasionally  permanently.  In  oblique 
fractures  of  the  humerus  in  which  autoextension  by  the  weight  of 
the  limb,  and  aided  by  splints,  does  not  succeed  in  overcoming 
overlapping,  extension  by  weight  and  pulley  with  the  patient  in  bed 
and  the  limb  in  proper  position,  continued  for  two  or  three  weeks, 
will  yield  the  best  results.  If  extension  is  employed  in  oblique 
fractures  of  the  femur  and  humerus,  it  should  be  continued  until  the 
consolidation  is  firm  enough  to  prevent  overlapping,  and  the  weight 
graded  to  the  age  of  patient  and  the  amount  of  muscular  resistance 
to  be  overcome — generally  from  ten  to  twenty-five  pounds.  The 
necessary  counterextension  is  made  by  the  weight  of  the  body,  by 
elevating  the  foot  of  the  bed.  Extension  is  always  combined  with 
an  appropriate  fixation  dressing,  to  guard  against  rotary  and  lateral 
displacement,  and  to  aid  the  extending  force  in  effecting  muscular 
rest  and  relaxation. 

The  ambulatory  treatment  of  compound  fractures  of  any  of 
the  large  long  bones  can  not  be  condemned  too  strong!)-  ;  repose 
of  the  entire  body  in  the  recumbent  position  is  an  essential 
prerequisite  to  insure  complete  rest  of  the  fractured  limb,  and 
mu.st  be  strictly  enforced  until  union  between  the  fragments  is 
sufficiently  firm  to  place  full  reliance  on  a  fixation  dressing.  An- 
other very  important  element  in  the  treatment  of  a  fracture  of  the 
long  bones,  particularly  of  fractures  of  the  femur  and  humerus 
and  fracture  of  both  bones  of  the  leg  and  forearm,  is  to  include 
in  the  fixation  dressing  both  adjacent  joints  :  the  knee,  ankle,  and 
foot  in  fractures  of  both  bones  of  the  leg  ;  the  knee  and  pelvis  in 
fractures  of  the  femur  ;  the  hand,  as  far  as  the  base  of  the  fingers, 
and  the  elbow-joint  in  fractures  of  both  bones  of  the  forearm  ;  and 
the  shoulder  and  elbow  in  fractures  of  the  humerus.  In  the  treat- 
ment of  fractures  of  the  .spine  and  suppurating  compound  fractures 
of  the  thigh  and  leg  Verity's  susjKMision  splint  (Vig.  352)  constitutes 
a  most  vahial^le  dressing.  The  technical  difficulties  encountered  in 
the  use  of  an  external  sujjpfjrt  i)ennitting  a  ciiange  of  dressing  of  the 
35 


546 


COMPOUND    FRACTURES. 


wound  without  removing  it  are  exceedingly  great,  and  often  insur- 
mountable. The  antiseptic  treatment  of  the  wound  demands  the 
first  claim  on  the  attention  of  the  surgeon,  and  immobilization  of  the 
fragments  in  proper  position  the  second  ;  but  if  these  two  indica- 
tions can  be  met  efficiently  at  the  same  time,  as  can  often  be  done 
by  direct  fixation  of  the  fragments,  this  method  is  entitled  to  full 
recognition  in  well-selected  cases.  The  immobilization  of  the 
fragments  has  very  properly  been  designated  long  ago  by  Billroth 
as  the  best  antiphlogistic  in  the  treatment  of  compound  fractures. 
Manufactured  splints  have  become  almost  obsolete  in  the  treat- 
ment of  fractures,  simple  and  compound.  Carved,  metallic,  and 
plastic  splints  molded  on  any  other  model  than  the  fractured  limb 
can  never  be  made  to  fit,  and  copious  padding,  which  is  often 
made  use  of  to  correct  the  mechanical  defects,   usually  seriously 


Fig.  352. — Verity's  suspension  splint. 


impairs  their  efficiency  in  maintaining  retention.  Circular  plaster- 
of-Paris  dressings  are  absolutely  contraindicated  in  the  treatment 
of  a  recent  compound  fracture,  a  statement  fully  indorsed  by  the 
experience  of  Volkmann  and  P.  Bruns.  Bardeleben  was  very 
partial  to  the  use  of  fenestrated  plaster-of-Paris  splints,  as  he  was 
decidedly  opposed  to  the  removal  of  the  first  fixation  dressing  until 
the  fracture  was  united.  He  made  the  fenestra  laree  enough  to 
secure  free  access  to  the  wound,  and  for  the  application  of  a  large 
moist  antiseptic  compress.  But  such  splints  often  interfere  seriously 
with  the  antiseptic  treatment  should  the  wound  become  infected,  as 
the  fenestra  can  not  be  made  of  sufficient  size  for  the  antiseptic 
treatment  of  the  wound  without  impairing  its  efficiency  in  maintain- 
ing fixation.  Different  kinds  of  supports  must  be  employed  to 
meet  the  peculiarities  of  individual    cases.      Some  form  of  plastic 


FIXATION    DRESSING. 


547 


splint  serves  an  excellent  purpose  in  immobilizing  a  recent  compound 
fracture.  Gutta-percha,  felt,  leather,  and  plaster-of-Paris  are  the 
materials  that  have  had  the  most  extended  trial  in  the  construction 
of  such  splints,  and  of  these,  the  last  is  the  cheapest  and  most 
valuable.  Gutta-percha  is  somewhat  expensive  ;  felt  lacks  strength  ; 
leather  takes  a  long  time  to  dry,  and  none  of  them  can  be  so 
accurately  molded  to  the  surface  of  the  limb  as  plaster-of-Paris. 
Dr.  Buchanan,  of  Pittsburg,  has  devised  an  excellent  method  for 
applying  such  plaster  splints.  He  uses  crinoline,  cut  to  fit  the  sur- 
face of  the  limb  accurately, — from  four  to  eight  layers, — and  next 


Fig.  353._Fenestrated  plaster-of-Paris  splint  for  lower  extremity  (von  Esmarch). 


Fig.  354._Open-wound  treatment  in  fenestrated  plaster-of- Paris  splint  (von  Esmarch). 

to  the  limb  a  layer  of  lintin, — a  form  of  compressed  cotton, — for 
the  protection  of  tlic  skin.  After  the  plaster  has  been  rubbed  into 
the  meshes  of  the  crinoline,  the  different  layers  are  fastened  togetiier 
by  ordinary  pins,  which  are  converted  into  staples  by  a  pin- 
stapling  tool.      He  gives  the  following  directions  : 

"  I.  The  plaster  should  be  rubbed  well  into  each  layer  of  crino- 
line .separately  by  hand. 

"  2.  In  handling  the  splint,  care  should  be  taken  lest  the 
plaster  be  shaken  out. 


548 


COMPOUND    FRACTURES. 


"3.  In  soaking  the  splint,  seize  the  open  ends,  one  in  each 
hand,  and  immerse  gently  in  warm  water,  keeping  hold  of  the 
splint  to  prevent  the  plaster  from  being  washed  out  of  the  meshes 
of  the  crinoline. 

"  4.  Apply  one  splint  to  the  limb  with  a  roller  bandage  ;  apply 
the  other  splint  to  the  other  side  of  the  limb  with  another  muslin 
roller. 

"  5.   In  reapplying  the  splints,  the  same  plan  should  be  followed, 


Fig.  355. — Dorsal  hemp  plaster-of- Paris  splint  for  fractures  of  the  leg  (after  Beely). 


F'g-  356- — Bridge  plaster-of-Paris  splint  (after  Pirogoff). 


Fig-  357-— Hemp  plaster-of-Paris  splint  for  complicated  fractures  of  the  knee-joint 

(after  Beely). 

— of  applying  each  splint  with  a  separate  roller, — so  that  they  may 
fit  as  before  and  not  pinch  the  limb  in  front  or  behind. 

"6.   Never  use  any  pads,  for  this  destroys  the  fit  of  the  splints. 

"  7.  If  any  points  of  pressure  occur,  cut  an  opening  in  the 
splint  to  correspond  exactly  with  the  point  of  irritation.  This  very 
rarely  happens." 

This  description  applies  more  particularly  to  fractures  of  the 
leg  requiring  two  lateral  splints.  In  fractures  of  the  thigh  two 
lateral  or  anteroposterior  splints  with  a  space  of  an  inch  or  two 
between  them,  and  extending  from  the  tuberosity  of  the  ischium  to 


FIXATION    DRESSING. 


549 


below  the  knee  behind,  and  from  the  groin  to  the  same  distance 
below,  or  from  the  crest  of  the  ilium  on  the  outer  side,  and  from 
the  perineum  on  the  inner  side  to  below  the  knee,  will  immobilize 
the  femur  most  effectually.  An  outer  splint,  encircling  one-half  of 
the  arm  and  extending  from  the  top  of  the  shoulder  to  below  the 
elbow,  is  an  excellent  way  in  which  to  immobilize  a  fracture  in  any 
part  of  the  humerus  above  the  junction  of  the  middle  with  the 
lower  third.  In  fractures  of  the  forearm  anteroposterior  splints 
reaching  from  the  bend  of  the  elbow  to  the  base  of  the  fineers 


Fig.  358. — Same  splint  with  suspension  of  the  limb  (after  Beely). 


'^'^^^^^^^r- 


Fig.  359- — Posterior  plaster  splint  for  fractures  of  the  leg  (after  Herrgott). 


constitute  an  excellent  method  of  fixation.  In  molding  the  splints 
for  such  fractures,  care  must  be  exercised  not  to  make  lateral  pres- 
sure sufficiently  to  force  the  fragments  in  the  direction  of  the  inter- 
csseous  space.  In  Colics'  fracture  of  the  radius  an  anterior  splint 
will  suffice.  The  .strength  of  the  splint  is  regulated  by  the  number 
of  layers  of  crinoline  u.scd.  If  a  strong  support  is  required,  as  is 
often  the  case  in  compound  fractures,  more  especially  in  in.stances 
where  only  (Mie  splint  is  applicable,  the  requisite  strength  can  easily 
be   .secured   by   making  a  double  plastic    splint,    and    interposing 


550 


COMPOUND    FRACTURES. 


between  the  two  splints  an  additional  metallic  support,  such  as 
strips  of  tin,  sheet-iron,  aluminum,  or  wire.  To  make  such  splints 
more  durable  the  outside  surface  can  be  covered  with  a  coat  of 
shellac  or  glue.  By  incorporating  at  the  margins  of  the  splint,  at 
desirable  points,  rings  or  loops,  suspension  can  be  combined  with 
fixation  without  any  additional  mechanical  contrivance. 

Plastic  splints,  as  described,  do  not  interfere  with  extension, 
which  is  so  necessary  in  the  successful  treatment  of  all  oblique 
fractures  of  the  femur,  and  which  is  occasionally  necessary  in  similar 
fractures  of  the  humerus.  Should  diminution  in  the  size  of  the 
dressing  or  inflammatory  swelling  impair  the  fitting  qualities  of  the 

splint  sufficiently  to  render  it  inse- 
cure in  maintaining  retention,  it  is 
preferable  to  make  a  new  splint 
rather  than  to  make  use  of  pads. 
A  splint,  to  be  safe  and  efficient, 
should  fit  accurately  the  surface  of 
the  limb  to  which  it  is  applied,  so  as 
to  distribute  the  pressure  necessary 
to  secure  fixation  equally  and  evenly 
over  that  part  of  the  limb.  Splints 
that  do  not  fit  are  frequently  the 
cause  of  localized  pressure  necrosis, 
and  often  over  points  that  it  is  im- 
portant to  preserve  in  an  intact  con- 
dition for  the  purpose  of  maintaining 
efficient  immobilization  of  the  frac- 
ture. Allusion  in  this  regard  to  the 
frequency  with  which  decubitus  over 
the  heel  is  seen  as  the  direct  result 
of  harmful  pressure  of  an  ill-fitting 
posterior  support  in  the  treatment 
of  fractures  of  the  leg  will  illustrate 
the  force  of  this  statement.  The  plas- 
tic splints  can  often  be  relied  upon 
throughout  the  entire  treatment  in 
immobilizing  the  fracture  ;  more  fre- 
quently, however,  after  the  danger  from  infection  has  passed,  the 
swelling  following  the  accident  has  subsided,  and  the  risks  of  over- 
lapping of  the  fragments  have  been  diminished  by  a  beginning  bony 
consolidation  they  are  removed,  and  a  circular  plastic  splint  is  sub- 
stituted. The  application  of  a  well-fitting  efficient  circular  plaster- 
of-Paris  splint  requires  skill  and  experience.  It  is  the  novice  and 
the  surgeon  devoid  of  any  mechanical  skill  who  are  responsible  for 
the  many  disastrous  results  following  the  use  of  the  circular  plastic 
splint,  and  not  the  method.  In  Avell-selected  cases  this  method  of 
fixation  is  the  one  that  offers  the  greatest  security  against  displace- 
ment of  the  fragments  and  is  attended  by  the  least  risk.     A  circular 


Fig.  360. — Plaster- of- Paris  strips 
dressing  for  fractures  of  the  femur 
(Pirogoff). 


FIXATION    DRESSING.  551 

splint  should  always  extend  from  the  periphery  of  the  limb,  and 
should  include  the  joint  on  the  proximal  side  of  the  fracture.  In 
fractures  of  the  leg  it  must  extend  from  the  base  of  the  toes  to 
some  distance  above  the  knee  ;  in  fractures  of  the  thigh,  from  the 
base  of  the  toes,  including  the  corresponding  side  of  the  pelvis  ;  in 
fractures  of  the  forearm,  from  the  base  of  the  fingers  to,  or,  still 
better,  above,  the  elbow  ;  in  fractures  of  the  humerus  it  must 
embrace  both  of  the  adjacent  joints.  In  cases  justifying  the  use  of 
the  circular  splint  it  is  superfluous  and  harmful  to  interpose  between 
it  and  the  surface  of  the  limb  a  thick  cushion  of  cotton,  as  by 
so  doing  fixation  is  lost,  and  if  allowed  to  remain  until  repair  is 
completed,  vicious  union  is  the  probable  result.  If  the  splint  is 
applied  smooth!}^  and  carefully  from  the  periphery  of  the  limb  to 
the  requisite  distance  on  the  proximal  side  of  the  fracture,  the  uni- 
form circular  support  is  the  very  best  means  of  preventing  swelling 
and  of  securing  the  necessary  degree  of  fixation.  The  limb  must 
be  protected  by  a  layer  of  lintin  or  a  smooth  layer  of  loose  absor- 
bent cotton,  not  more  than  half  an  inch  in  thickness,  held  in  place 
by  a  gauze  or  flannel  roller,  over  which  the  plaster  bandage, 
immersed  for  the  requisite  length  of  time  in  warm  water,  is  applied, 
beginning  at  the  periphery  and  terminating  at  the  various  points 
just  indicated.  The  plaster  roller  should  be  allowed  to  take  its 
own  course  upward  and  downward  at  different  angles,  in  order  to 
apply  it  smoothly,  making,  at  the  same  time,  as  few  reverses  as 
possible.  Subcutaneous  bony  prominences  must  be  protected  by 
an  additional  layer  of  cotton.  Before  applying  the  dressing,  and 
during  the  time  required  for  the  setting  of  the  plaster,  the  frag- 
ments must  be  brought  in  accurate  coaptation,  and  held  in  this 
position  until  the  mechanical  support  is  such  as  to  render  manual 
extension  and  fixation  unnecessary.  With  a  limb  immobilized  in 
such  a  manner  the  patient  will  be  able  to  leave  his  bed  and  walk 
about  with  the  aid  of  crutches  at  an  early  date  in  fractures  of  the 
leg,  and  somewhat  later  in  fractures  of  the  femur. 

Unremitting  watchfulness  is  always  essential  in  the  successful 
treatment  of  fractures.  Negligence  is  inexcusable  and  often  leads  to 
legal  complications.  The  fingers  and  toes  must  always  remain  acces- 
sible to  insi)ection,  as  from  their  appearance  the  surgeon  can  de- 
termine the  condition  of  the  circulation,  to  which  tlie  patient's  atten- 
tion should  be  called  in  order  that  he  may  give  timely  warning  of 
approaching  danger  from  an  imj)eded  circulation  caused  by  harmful 
circular  constriction.  In  such  an  event  no  time  is  to  be  lost  in  re- 
lieving the  pressure  by  cutting  the  splint  longitudinally  on  one  side, 
increasing  the  space  in  tin's  way  sufficiently  to  relieve  the  embar- 
ras.sed  circulation.  Various  instruments  have  been  devised  for  this 
purpo.sc,  but  few,  if  any,  of  tlicm  have  answered  the  expectations  of 
their  inventf)rs,  much  less  those  of  the  purchasers.  The  application 
of  vinegar  or  acetic  acid  in  tlie  line  of  the  proj)osed  cut  softens  the 
pla.ster  anrl  prcpan^s  the  way  for  an  easier  cutting  of  the  splint.      A 


552 


COMPOUND    FRACTURES. 


stout  blade  of  a  pocket-knife  will  accomplish  this  task  as  quickly 
and  safely  as  the  many  cumbersome  and  expensive  plaster  shears 
or  saws.  A  splint  that  has  been  cut  longitudinally  soon  becomes 
useless  as  an  efficient  means  of  fixation,  and  must  be  replaced  by  a 
new  one  if  union  at  the  seat  of  fracture  is  not  sufficiently  secure  to 

guard  against  overriding 
of  the  fragments. 

It  has  been  pre- 
viously stated  that  the 
circular  plastic  splint 
should  never  be  used  in 
the  treatment  of  a  re- 
cent compound  fracture. 
This  rule,  like  every 
other,  has  its  exceptions. 
These  exceptions  present  themselves  more  especially  on  the  battle- 
field and  in  the  practice  of  railway  surgeons,  where  the  patients  often 
have  to  be  transported  great  distances  from  the  place  of  injury  to  the 
nearest  hospital,  residence,  or  boarding-house.  In  transporting  a 
patient  the  subject  of  a  compound  fracture,  immobilization  is  ab'so- 
lutely  necessary  to  prevent  additional  injury  to  the  soft  tissues  dur- 
ing the  journey,  and  no  other  method  of  fixation  accomplishes  this 
object  to  the  same  degree  as  does  the  circular  plaster-of- Paris  splint. 
When  employed  for  this  purpose,  the  limb  should  be  enveloped  in  a 
thick  cushion  of  cotton,  so  that  no  harm  can  result  from  the  swelling 
at  the  seat  of  injury.      When  the  patient  reaches  his  destination,  the 


Fig.  361. — Von  Bergmann's  plaster-of- Paris  bandage 
saw. 


Fig.  362.— German  plaster  bandage  shears 


circular  splint  should  be  removed  and  replaced  by  a  plastic  lateral 
splmt.  The  value  of  immediate  immobilization  in  the  treatment  of 
compound  fractures  in  patients  requiring  transportation  for  some 
distance  has  been  demonstrated  by  an  extensive  experience  in  mih- 
tary  and  emergency  practice,  and  no  other  dressing  can  compare  in 
comfort  and  efficiency  with  the  circular  plastic  splint.  The  plastic 
splmt  IS  the  splint  of  the  future  in  the  treatment  of  compound  frac- 
tures ;  it  will  soon  almost  entirely  displace  the  manufactured  splints 
m  the  surgeon  s  armamentarium.  Bowling  has  well  said  :  "  Carved 
and  manufactured  splints  generally  fit  nobody,  and  are  to  be  re- 


FIXATION    DRESSING. 


553 


jected  as  not  only  expensive,  but  damaging."  Different  kinds  of 
bracketed  splints  have  been  in  use  since  the  time  of  Abernethy.  If 
a  splint  of  this  kind  is  required,  it  can  very  readily  be  extemporized 
by  connecting  two  plastic  splints  by  an  iron  bar,  curved  in  such  a 
manner  as  to  suit  the  locality  of  the  wound  and  to  adapt  itself  to 
the  dressing.  For  good  and  substantial  reasons  the  old-fashioned 
fracture  box  has  almost  entirely  disappeared  from  the  surgical 
arena  in  all  parts  of  the  world.  The  bran  dressing,  introduced  into 
practice  by  Rhea  Barton  in  connection  with  the  fracture  box,  has 
met  a  similar  fate,  its  place  having  been  taken  entirely  by  the 
modern  antiseptic  dressing.  In  compound  fractures  of  the  femur, 
when  extension  constitutes  an  essential  feature  in  their  successful 
treatment,  Hodgen's  extension  or  N.  R.  Smith's  (see  Figs.  232  and 
230)  anterior  suspension  splint  will  frequently  meet  the  indications 
of  the  mechanical  treatment  better  than  any  other  method  of  fixation. 
In  review  it  may  be  stated  that  the   mechanical   treatment  of 


„1]]]F^i-'*iii""fi'i; 


Fig.  363. — Bracketed  plaster-of-Paris  suspension  splint  for  elbow  (von  Esmarch). 


compound  fractures  consists  of  direct  means  of  fixation  in  cases 
demanding  such  interference,  and,  if  such  a  course  is  not  called  for 
by  the  nature  of  the  injur>%  of  careful  reposition  and  fixation  of 
the  fractured  bone  by  an  efficient  mechanical  support,  which  should 
fit  the  limb  with  sufficient  accuracy  to  prevent  decubitus,  be  of 
sufficient  strength  to  maintain  coaptation,  and  should  not  interfere 
with  the  circulation  in  the  injured  limb.  And,  finally,  the  plastic 
splint  is  the  one  that  accomplishes  these  objects  with  the  greatest 
degree  of  certainty  and  with  the  least  interference  with  the  antisep- 
tic treatment  and  dre.s.sing  of  the  complicating  wound.  Immobili- 
zation of  a  fracture  mu.st  be  continued  until  the  union  is  firm  enough 
to  balance  muscular  action,  and  in  fractures  of  the  lower  extremi- 
ties to  bear  the  weight  of  the  body.  The  length  of  time  for  bony 
union  to  take  place  varies  much,  and  is  dependent  largely  on  the 
age  of  the  patient,  the  scat  and  extent  of  the  fracture,  and,  in  com- 
pr^und    fractures,   on   the   condition    of   the   wound.      In    children, 


554  COMPOUND    FRACTURES. 

under  favorable  conditions  a  fracture  of  any  of  the  long  bones  may 
be  repaired  sufficiently  to  dispense  with  any  kind  of  fixation  dress- 
ing at  the  end  of  three  or  four  weeks,  while  in  the  adult  and  the 
aged  from  two  to  three  months  are  often  required.  Harm  results 
if  the  fixation  splint  is  removed  too  soon,  as  well  as  if  its  use  is 
prolonged  beyond  the  necessary  length  of  time.  Secondary  dis- 
placement and  bending  at  the  seat  of  fracture  are  liable  to  occur  in 
the  former,  and  muscular  atrophy  and  stiffening  of  joints  in  the 
latter,  case.  Active  and  passive  motion  must  never  be  made,  regard- 
less of  the  location  of  the  injury,  until  the  fracture  has  firmly  united, 
as  preinature  efforts  of  this  kind  are  more  likely  to  provoke  than  pre- 
vent stiffness  and  ankylosis.  Tins  statemejzt  applies  with  special  force 
to  fractures  extending  into  and  near  joints.  The  old  teacliing  to  the 
effect  that  in  such  cases  ankylosis  is  likely  to  follozv  unless  passive 
motion  is  commenced  within  a  week  or  tzvo  after  the  iijtiry  lias 
occurred  is  based  upon  wrong  principles,  and  certainly  lias  led  to 
vicious  practice. 

Gunshot  Fractures. — A  few  remarks  on  the  modern  treatment 
of  gunshot  fractures  will  be  in  place  here.  Besides  the  ordinary 
characteristics  of  gunshot  wounds,  wherever  the  anatomic  location 
of  the  injury,  bullet  wounds  of  the  extremities,  when  complicated 
by  fracture  or  joint  injury,  present  to  the  surgeon  special  clinical 
features  of  great  importance.  The  existence  of  a  gunshot  fracture, 
regardless  of  the  extent  of  bone  injury,  no  longer  furnishes  a 
legitimate  indication  for  primary  amputation.  Such  injuries,  under 
appropriate  aseptic  and  mechanical  treatment,  are  amenable  to  a 
satisfactory  repair,  with  good  functional  results,  in  the  course  of 
time.  They  are  the  cases  that  tax  the  ingenuity  of  the  surgeon  to 
the  utmost  in  applying  and  maintaining  the  necessary  mechanical 
support  until  the  fracture  heals  by  bony  consolidation  with  the  limb 
in  a  satisfactory  useful  position.  The  wound  should  never  be 
probed  or  otherwise  interfered  with.  It  should  be  dressed  with  the 
borosalicylic  powder  and  cotton  compress  securely  fixed  in  place 
with  bandage,  or,  still  better,  with  strips  of  adhesive  plaster  and 
bandage.  In  gunshot  fractures  of  the  femur  .extension  with  immo- 
bilization will  now,  as  it  has  for  a  long  time,  constitute  the  generally 
accepted  treatment.  A  determined  strong  protest  must  be  made 
against  the  unnecessary  removal  of  detached  and  partially  detached 
fragments  of  bone.  If  the  wound  remains  aseptic,  loose  fragments 
of  bone  will  not  only  retain  their  vitality,  but  will  take  an  im- 
portant part  in  the  restoration  of  the  continuity  of  the  bone  and 
add  materially  to  the  functional  result.  Debridement,  more  or  less 
extensive,  becomes  necessary,  and  should  be  performed  only  in  case 
the  wound  becomes  infected.  In  such  an  event  the  loose  infected 
fragments  of  bone  should  be  removed  promptly,  free  tubular 
drainage  established,  and  the  wound  throughout  subjected  to 
thorough  disinfection.  If  the  ordinary  measures  should  fail,  con- 
tinuous irrigation  with  a  saturated  solution  of  acetate  of  aluminum 


GUNSHOT    FRACTURES. 


555 


or  Thiersch's  solution  will  veiy  often  bring  about  the  desired  results 
and  obviate  the  necessity  for  a  secondary  amputation.     Fixation  and 


Fig.  364. — Eflfect  of  the  small-caliber  bullet  on  the  shafts  of  the  long  bones  (Bruns). 


Fig.  365. — Effect  of  the  small-caliber  bullet  on  the  epiphyseal  extremities  of  the  long 

bones  (IJruns). 

suspension   in   such   cases  will   not  only   procure   comfort  for  the 


556 


COMPOUND    FRACTURES. 


patient,  but  will  answer  an  excellent  purpose  in  securing  and  main- 
taining coaptation  and  in  facilitating  drainage  and  irrigation.  As 
soon  as  the  fracture  has  united  with  sufficient  firmness  to  render 
extension  unnecessary,  the  limb  should  be  immobilized  in  a  circular 
plaster-of- Paris  splint,  in  the  manner  previously  described,  after 
which  the  patient  is  permitted  to  walk  about  with  the  aid  of 
crutches.      In  gunshot  fractures  of  the  leg  early  immobilization  in  a 

circular  plastic  splint  is 
to  be  advised  and  yields 
the  most  gratifying  re- 
sults. Watchful  con- 
trol of  patients  suffer- 
ing from  such  injuries 
and  treated  by  the  use 
of  the  plaster-of-Paris 
bandage  is  essential  in 
guarding  against  disas- 
trous complications  and 
in  obtaining  satisfac- 
tory functional  results. 
Gunshot  injuries 
implicating  any  of  the 
large  joints  are  now 
within  the  range  of 
successful  conservative 
treatment.  I  have  seen, 
in  the  military  hospi- 
tals, both  in  Greece  and 
Turkey  during  the  late 
war  and  during  the 
Spanish-American  war 
in  Cuba  and  Porto 
Rico,  gunshot  wounds 
of  the  hip-,  knee-, 
ankle-,  shoulder-, 
elbow-,  and  wrist- 
joints,  not  only  recover 
without  any  operative 
interference  whatever, 
but  in  many  of  the 
cases  a  fair  degree  of  motion  and  good  use  of  the  limb  rewarded 
the  most  conservative  treatment.  With  a  view  to  showing  what 
the  modern  treatment  of  gunshot  fractures  is  capable  of  accomplish- 
ing in  saving  life  and  limb,  I  will  very  briefly  describe  a  few  of  the 
many  cases  that  came  under  my  own  personal  observation  in  Greece, 
Turkey,  Cuba,  and  Porto  Rico. 

The  following  cases  came  under  my  observation  in  Greece  and 
Turkey  : 


Fig.  366. — Old  gunshot  fracture  of  the  lower  end 
of  the  humerus  ;  bullet  embedded  in  the  bone  between 
the  condyles. 


GUNSHOT    FRACTURES.  55/ 

Case  I. —  Wound  of  Right  Knee-joint. — Received  in  Epirus.  The  bullet  fractured 
the  internal  condyle  of  the  femur,  opened  the  knee-joint,  and  was  removed  through  an 
incision  over  the  outer  aspect  of  the  joint.  Wound  healed.  Joint  motion  was  limited, 
and  capsule  of  joint  was  thickened. 

Case  2.  —  Gunshot  Fracture  of  Leg,  icith  Extensive  Coinviinution  of  Fibula. — 
Wound  received  during  the  tirst  week  of  the  war.  Healing  by  secondary  intention  and 
slow  formation  of  callus  followed. 

C.\SE  3.  —  Cotniiiinuttd  Gunshot  Fracture  of  the  Tibia. — Many  fragments  of  bone 
were  removed  soon  after  the  injury  was  received,  leaving  a  large  bone  defect.  Wound 
healed.  No  union  occurred  and  but  slight  callus  production.  An  operation  for  pseudar- 
throsis  will  become  necessary  in  the  near  future. 

Case  4. — Gunshot  Wound  of  Knee-joint  luith  Extensive  Comminution  of  the 
Internal  Tuberosity  of  the  Tibia. — Patient  was  a  captain  in  the  Greek  army.  First 
dressing  was  applied  fifteen  hours  after  the  injury  was  received.  Wound  was  redressed 
on  the  sixth  day.  Bullet  passed  through  the  joint  and  escaped  between  the  head  of  the 
fibula  and  the  external  condyle  of  the  femur.  Slight  suppuration  ensued.  Wound  now 
healed  ;  capsule  of  the  joint  and  para-articular  tissues  remained  somewhat  swollen  and 
indurated.      Joint  motion  was  limited. 

Case  5.  —  Gunshot  Wound  of  Knee  joint. — The  bullet  perforated  the  external 
condyle  of  the  femur,  and  passed  out  over  the  inner  aspect  of  the  joint.  There  was 
moderate  swelling  of  joint,  but  no  suppuration.  Wound  healed  by  primary  intention. 
Recovery  with  fair  motion  of  joint  followed. 

Case  6. — Cretan.  Gunshot  Wound  of  Shoulder- joint. — Bullet  passed  through  the 
head  of  humerus  and  joint  from  behind  ;  point  of  exit  below  the  coracoid  process.  Fistu- 
lous opening  remained,  through  which  a  limited  amount  of  pus  escaped  daily.  Ankylosis 
not  complete.  Considerable  atrophy  of  deltoid  muscle,  which  may  have  been  due  to 
injury  of  circumflex  nerve,  ensued. 

Case  7. —  Gunshot  Fracture  of  Thigh. — Injury  received  four  months  ago.  Wound 
healed  ;  bone  united  by  massive  callus  ;  limb  considerably  shortened  and  femur  curved. 

Case  8.  —  Gunshot  Fracture  of  Patella,  Opening  Knee-joint. — Secondary' suturing 
of  patella  was  done,  with  satisfactory  result.  Motion  of  knee-joint  was  greatly  impaired, 
a  condition  in  part  due  to  the  swelling  and  induration  of  the  soft  tissues  that  still  remained. 
Suturing  material,  silkworm-gut ;  operator,  Professor  Galvani. 

C.A.SE  9. — Gunshot  Fracture  of  Both  Bones  of  the  Forearm.  —  Bullet  and  loose  frag- 
ments of  bone  were  removed  in  the  field-hospital.  Wound  healed.  No  union  and  no 
callus  formation  followed. 

Case  10. — Gunshot  Fracture  of  the  Humerus. — Bullet  passed  through  the  arm  near 
the  middle.  Nerves  escaped  injury.  Healing  by  primary  intention  occurred.  No 
splints  were  used.  Fixation  was  accomplished  by  bandaging  arm  to  the  side  of  the  chest 
with  forearm  flexed  and  supported  by  the  same  bandage.  Union  by  bony  callus  with 
good  functional  result  followed. 

Case  II.  —  Gunshot  Fracture  of  Fetnur. — Infection  occurred.  Secondary  ampu- 
tation was  done.  Osteomyelitis  of  the  bone  in  the  stump  made  it  necessary  to  perform  a 
second  operation,  which  consisted  in  enucleating  the  bone.  Wound  still  suppurated  and 
healing  slowly  followed  by  granulation. 

Gunshot  Fractures  in  the  Military  Hospitals  in  Turkey. 

Case  I.  —  Gunshot  Fracture  of  the  Humerus  Implicating  the  Shoulder-joint. — Bullet 
entered  in  front,  passed  through  the  head  of  the  humerus,  and  e.scaped  behind.  Infec- 
tion followed.  Secondary  resection  of  about  three  inches  of  the  upper  end  of  the  bone 
was  made,  and  pieces  of  clothing  were  removed  from  the  wound.  Posterior  incision 
healed.  Fistulous  opening  remained  in  front.  Patient  had  very  little  use  of  arm,  but 
his  general  condition  was  good. 

Case  2.  —  Gunshot  Wound  of  Knee  joint. — Bullet  commiinited  internal  condyle  of 
femur  and  penetrated  the  joint.  Extraction  of  bullet  and  atypical  resection  of  joint  were 
done  in  the  field-hospital.  Primary  healing  of  the  wound  followed.  Joint  partially 
ankylosed,  with  leg  in  useful  position. 

Case  3.  —  Gunshot  Wound  of  A'nee  joint. — Bullet  located  by  the  Kiintgen  ray. 
No  .suppuration  occurred.  Incision  was  made  on  both  sides  of  joint  and  bullet  ex- 
tracted. Primary  healing  of  operation  wounds  and  almost  perfect  joint  function  re- 
sulted. 

Cask  4.  —  Gunshot  Injury  of  Shoulder-joint. — Wounds  of  entrance  and  exit  were 
enlarged,  through  wliich  comminuted  fragments  of  the  head  of  the  humerus  were  removed. 
Wounds  healed.      I'air  degree  of  motion  followed. 

Case  t^.  — Gunshot  Injury  of  Shoulder-joitit.  —  ^\i\\G.\.  passed  obliquely  through  the 


558  COMPOUND    FRACTURES. 

joint.  Anterior  and  posterior  incisions  were  made,  through  which  loose  fragments  from 
the  head  of  the  humerus  were  removed.  Operation  was  performed  in  the  field-hospital. 
Slight  infection  ensued.  Fistulous  opening  remained  behind.  Anterior  incision  healed 
by  primary  intention.      Use  of  arm  was  limited. 

Case  6.  —  Gunshot  Wound  of  Shoulder-joint. — Debridement  done  in  the  field- 
hospital.  Wounds  of  entrance  and  exit  healed  rapidly.  Function  of  joint  and  arm 
returned  gradually. 

Case  7. —  Gunshot  Wound  of  Elboxv- joint. — Bullet  passed  obliquely  through  the 
joint,  fracturing  the  internal  condyle  of  the  humerus.  Primary  atypical  resection  of 
joint  was  made.  Infection  followed.  Fistulous  opening  remained  behind  the  joint. 
Active  motion,  none  ;  passive  motion,  slight. 

Case  8.  —  Gunshot  Wotind  of  Knee-joint. — Primary  resection  was  done.  There  was 
great  comminution  of  articular  ends  of  femur  and  tibia.  Wounds  healed  without  suppu- 
ration.     Consolidation  was  not  complete  after  two  months  and  a  half. 

Case  9.  —  Gunshot  Wound  of  Knee-joint. — Secondary  resection  was  done.  Slight 
infection  followed.  Healing  took  place  by  granulation,  with  limb  in  good  position.  Bony 
union  was  quite  firm. 

Case  10. —  Volunteer,  Fourteen  Years  Old.  Gunshot  Wound  of  Shoulder. — Bullet 
passed  from  before  backward,  about  an  inch  to  the  inside  of  the  surgical  neck  of  the 
humerus.  Wounds  healed  by  primary  intention.  Little  or  no  impairment  of  function 
of  the  muscles  of  the  arm  occurred. 

Case  II. — Gunshot  Fracture  of  the  Humei-us. — Infection  present.  Secondary 
amputation  was  done,  the  stump  healing  by  granulation. 

Case  12.  —  Gunshot  Fracture  of  Humerus. — There  was  great  loss  of  bone,  caused 
by  the  injury,  and  later  by  an  operation  for  the  removal  of  sequestra.  Although  the 
periosteum  was  preserved,  there  was  no  callus  at  the  end  of  two  months,  and  a  false 
joint  was  established. 

Case  13. — Resection  of  the  Shoulder-joint  for  Gunshot  Wound. — Operation  wounds 
healed.     Arm  remained  almost  useless.      Great  muscular  atrophy  followed. 

Case  14.  —  Resection  of  Elbow -joint  for  Gunshot  Wound. — Secondary  operation 
done  through  posterior  bayonet  incision.  Fistulous  openings  and  considerable  swelling 
of  soft  parts  remained.      Muscles  of  arm  and  forearm  were  much  atrophied. 

A  glance  at  the  foregoing  report  of  cases  from  the  Greco- 
Turkish  war  will  suffice  to  show  that  infection  and  bad  functional 
results  were  much  more  frequent  on  the  side  of  the  Turks,  a  cir- 
cumstance that  is  plainly  attributable  to  the  more  aggressive  treat- 
ment that  was  pursued.  The  Greek  physicians  seldom  interfered 
with  the  wounds,  and  pursued  throughout  a  most  conservative 
course,  while  the  military  surgeons  of  the  Turkish  army,  stimulated 
by  the  exainple  of  a  number  of  German  physicians,  resorted  too  fre- 
quently to  the  use  of  the  knife,  with  the  result  that  infection  of  the 
wound  was  a  much  more  frequent  occurrence,  and  the  primary 
debridement  and  resection  only  too  often  resulted  in  delayed  union, 
pseudarthrosis,  and  useless  limbs.  Primary  resection  of  a  recent 
gunshot  zvoiind  of  any  of  the  large  joints  has  become  an  unjustifiable 
surgical  procedure,  and  is  2Lnder  no  circumstances  permissible.  The 
indications  for  primary  amptttation  of  a  limb  for  gunshot  fracture 
should  at  present  be  restricted  to  cases  in  zvhich  the  nutrition  is  sus- 
pended or  seriously  threatened  by  the  existence  of  lesions  of  the  soft 
parts  incompatible  zvith  the  vitality  of  the  tissues  at  and  belozv  the  seat 
of  injury.  In  cases  of  doubt,  the  soldier  is  entitled  to  the  benefit  of  the 
same,  and  the  conservative  treatment  shoidd  be  carried  to  its  utmost 
legitimate  limits  until  the  appearajtce  of  complications  has  demonstrated 
its  futility,  and  dictates  the  propriety  of  j^esorting  to  a  imttilating  opera- 
tion. It  is  always  more  creditable  to  a  surgeon  to  save  a  limb  than 
to  remove  it,  and  the  soldier  is  entitled  to  the  benefit  of  conserva- 


GUNSHOT    FRACTURES. 


559 


tive  surgery  as  much  as  the  civihan,  and  the  dut}'  of  the  mihtary 
surgeon  of  the  future  should  and  will  be  to  limit  more  and  more  the 
indications  for  primary  amputation,  and  to  resort  to  means  and 
measures  that  further  lessen  the  necessity  for  secondarv  amputation. 

The  principles  that  should  guide  the  military  surgeon  in  the 
treatment  of  gunshot  wounds  of  joints  and  gunshot  fractures  were 
followed  more  closely  and  thoroughly  on  our  side  during  the 
Spanish-American  war  than  during  any  previous  campaign.  Prob- 
ing of  bullet  wounds  was  discouraged  from  the  very  beginning  and 
was  seldom  resorted  to,  and  the  first-aid  dressing  was  relied  upon 
largely  in  prevent- 
ing wound  infec- 
tion. Primary  am- 
putation was  re- 
served for  cases  in 
which  the  extent 
of  injuiy  to  the 
soft  tissues  made 
it  apparent  that 
gangrene  would 
follow  as  an  inevi- 
table result  under 
any  kind  of  con- 
servative treat- 
ment. Very  few 
secondary  ampu- 
tations were  made, 
and  only  in  cases 
in  which  gangrene 
or  sepsis  became 
an  imminent  source 
of  danger  to  life. 

One  of  the  first 
cases  of  gangrene  I 
saw  at  the  front  at 
the  P"irst  Division 
Hospital,  in  charge  of  Major  Wood,  U.  S.  A.,  was  a  gunshot  frac- 
ture of  the  femur  complicated  by  a  complete  transverse  tear  of  the 
po[>litcal  artery.  The  wound  of  entrance  was  over  the  inner  mar- 
gin of  the  patella,  and  that  of  exit  over  the  lower  and  outer  aspect 
of  the  thigh.  The  knee-joint  and  thigh  were  enormously  swollen, 
and  the  gangrene  had  extended  to  within  a  few  inches  of  the  knee- 
joint.  The  pulse  was  rai)id,  and  the  temjicrature  105°  F.  The 
amputation  was  made  at  the  seat  of  fracture,  above  the  comminuted 
condyles  of  the  femur,  by  making  a  long  oval  anterior  and  a  short 
oval  posterior  flap.  Notwithstanding  the  edematous  condition  of 
the  flaps,  the  wound  was  in  excellent  condition  three  days  later, 
and  the  temperature  normal. 


Fig.    367. — Old  gunshot    injury  of   hand ;  bullet  embedded 
partly  in  the  basal  phalanx  of  the  index-finger. 


560 


COMPOUND    FRACTURES. 


Among  the  wounded  Spanish  prisoners  I  found  several  cases  of 
gunshot  fractures  badly  infected,  and  secondary  amputation  became 
necessary  in  an  effort  to  ward  off  death  from  progressive  sepsis. 
In  the  majority  of  cases  of  gunshot  fracture  not  complicated  by 
serious  nerve  and  'C'essel  wounds,  the  results  under  the  most  con- 
servative treatment  were  excellent.  In  the  cases  of  compound  frac- 
tures in  which  late  suppuration  occurred  it  was  noticed  that  the  in- 
fection usually  commenced  about  the  margins  of  the  skin,  extending 
in  some  of  the  cases  to  the  seat  of  fracture  ;  in  others,  remaining 

localized.  There  can  be  no 
doubt  that  late  infection  in 
quite  a  number  of  cases 
resulted  from  subsequent 
probing  of  the  wound,  or 
in  consequence  of  unneces- 
sary removal  of  the  first-aid 
dressing. 

It  is  a  source  of  regret 
that  fixation  of  the  frac- 
tured limbs  by  plaster-of- 
Paris  splints  was  not  more 
generally  practised.  Owing 
to  the  want  of  reliable  plas- 
ter-of- Paris  we  had  to  resort 
to  various  kinds  of  splints 
and  single  and  double  in- 
clined planes  in  effecting 
immobihzation.  We  made 
very  extensive  use  of  the 
sheath  of  the  leaf  of  the 
royal  palm  as  a  material  for 
splints,  which  answered  an 
excellent  purpose,  as  it  is 
light,  porous,  and  can  be 
made  to  fit  the  surface  of 
the  limb  much  better  than 
splints  made  of  wood.  Many 
cases  of  gunshot  fracture  of 
large  joints,  in  which  one  or 
both  articular  extremities  were  extensively  comminuted  by  the  bul- 
let, healed  in  the  same  satisfactory  and  painless  manner  as  subcuta- 
neous injuries,  with  excellent  functional  results,  such  as  were 
seldom,  if  ever,  seen  during  the  Civil  War.  The  modern  treatment 
of  recent  gunshot  fractures  can  be  summed  up  briefly  as  follows  : 

1.  No  probing  of  the  wound. 

2.  No  primary  debridement. 

3.  Early  efficient  first-aid  dressing. 

4.  Immobilization  of  fracture,  preferably  by  plastic  splints. 


Fig.  368. — Gunshot  injury  of  forearm  ; 
point  of  bullet  buried  in  the  lower  end  of  the 
radius. 


REPAIR    OF    COMPOUND    FRACTURES.  56 1 

5.  Immobilization  combined  with  extension  if  there  is  a  tendency 
to  undue  shortening. 

6.  First-aid  dressing  must  not  be  removed  unless  this  becomes 
necessary  by  the  appearance  of  local  or  general  symptoms  that 
indicate  the  existence  of  wound  infection. 

Repair  of  Compound  Fractures. — It  is  generally  conceded 
that,  all  other  things  being  equal,  it  takes  a  somewhat  longer  time 
for  a  compound  fracture  to  consolidate  by  bony  union  than  a  sim- 
ple fracture.  This  apphes  to  fractures  in  which  the  complicating 
wound  remains  aseptic  and  heals  by  primary  intention.  The  dif- 
ference in  the  time  of  healing  between  a  simple  and  an  aseptic  com- 
pound fracture  depends  mostly  on  the  more  extensive  injury  to  the 


Fig.  369. — Recent  gunshnt  fracture  of  the  clavicle  ;  bullet  lodged  in  the  tissues  below 

the  fracture. 

soft  parts  in  the  latter,  and,  further  perhaps,  on  a  less  perfect  im- 
mobilization of  the  fracture,  owing  to  the  existence  of  an  external 
wound.  In  more  or  less  extensive  crushing  of  the  soft  tissues  at 
the  seat  of  fracture,  even  if  the  wound  remains  aseptic,  the  vas- 
cular supply  to  the  fragments  is  for  some  time  greatly  interfered 
with,  a  condition  unfavorable  to  the  speedy  repair  of  the  bone  injury. 
Callus  formation  is  also  greatly  retarded  by  comminution  of  the 
fractured  bone.  Callus  formation  is  stimulated  by  the  uninter- 
rupted accurate  contact  between  the  ends  of  the  fractured  bone.  A 
space  between  them  filled  in  with  detached  fragments  and  lacerated 
soft  tissues  always  constitutes  a  serious  obstacle  to  a  speedy  and 
.satisfactory  process  of  re[)air.  The  removal  of  loose  and  partially 
detached  fragments  is  always  followed  by  delayed,  and  not  in- 
36 


^62  COMPOUND    FRACTURES. 

frequently  by  nonunion.  If  the  wound  and  the  seat  of  fracture 
become  infected,  delay  of  union  follows  as  an  inevitable  consequence. 
Callus  production  does  not  take  place  to  any  extent  until  the  acute 
suppurative  process  has  subsided,  and  the  necrosis  of  the  fragments 
and  fractured  ends,  which  so  constantly  follows  the  osteomyelitis, 
creates  new  defects  that  are  often  repaired  with  the  greatest  diffi- 
culty by  late  profuse  callus  formation. 

Infection  and  suppuration  are,  for  good  reasons,  much  feared 
in  cases  of  extensive  comminution,  so  far  as  callus  production  is 


Fig-  370. — Bullet  embedded  in  upper  epiphysis  of  the  humerus. 


concerned,  as  all  the  loose  fragments,  and  many  with  limited 
attachments,  are  lost  by  necrosis.  Extensive  phlegmonous  inflam- 
mation of  the  soft  tissues  at  the  seat  of  fracture  seriously  retards 
repair  of  the  fracture,  aside  from  its  destructive  effects  on  bone  by 
causing  tension  and  by  preventing  speedy  vascular  connection  be- 
tween the  ends  of  the  fractured  bone.  Besides,  suppuration  at  the 
seat  of  fracture  always  destroys  more  or  less  of  the  two  bone- 
producing  tissues — medulla  and  periosteum.  The  torn  periosteum 
and  the  exposed  and  often  crushed  medullary  tissue  fall  an  easy 


REPAIR    OF    COMPOUND    FRACTURES. 


563 


prey  to  the  suppurative  process,  and  the  extent  of  their  destruction 
is  proportionate  to  the  intensity  and  extent  of  the  inflammatory 
process. 

In  the  treatment  of  a  recent  compound  fracture  the  surgeon 
must  pay  especial  attention  to  the  preservation  of  the  osteogenetic 
tissues.  Fragments,  loose  and  partially  detached,  must  be  saved 
whenever  possi- 
ble, and  the  lac- 
erated periosteum 
must  be  pre- 
served, placed, 
and  fixed  in  its 
proper  position 
around  the  frag- 
ments ;  the  med- 
ulla,  even  if 
crushed,  may 
prove  useful  in 
the  subsequent 
process  of  repair, 
and  is  utilized  in 
its  normal  ana- 
tomic location  as 
a  valuable  bone- 
producing  agent. 
Bruns  has  made 
successful  trans- 
plantations of 
bone  -  marrow  in 
the  lower  animals, 
and  in  the  light  of 
these  experiments 
it  appears  rational 
and  judicious  to 
preserve  this  tis- 
sue carefully  in 
dealing  directly 
with  the  seat  of 
injury.  T/ie  sur- 
^con  must  recog- 
nize the  impor- 
tance of  favoring 

callus  prodtiction  in  compound  fractures  by  saving  all  bone-producing 
tissues  compatible  with  the  nature  of  the  injury,  and  so  place  and  hold 
them  in  their  proper  relati't'c  anatomic  positions  by  direct  or  external 
means  of  immobilization  with  the  same  care  and  in  the  same  manner 
that  he  zvould  deal  with  ivounds  of  the  soft  tissues  in  which  different 
anatomic  structures  are  involved.      It  is  for  this   reason,  if  for  no 


Fig.  371. — Extensive  loss  of  bone  following  gunshot 
fracture  of  shaft  of  humerus  and  two  unsuccessful  operations 
for  pseudarthrosis.  Patient  a  lieutenant  in  Unitetl  States 
army,  wounded  in  the  Philippine  Islands  (Clinic,  Rush  Medi- 
cal College). 


04  COMPOUND    FRACTURES. 

Other,  that  the  buried  absorbable  suture  should  be  more  frequently 
employed  in  the  treatment  of  open  fractures.  If  the  wound  is,  or 
becomes,  infected,  the  surgeon  has  another  and  important  duty  to 
perform  in  protecting  the  bone-producing  tissues  by  establishing 
free  and  efficient  drainage,  and  in  taking  the  necessary  steps  to  effect  ■ 
secondary  disinfection  by  frequent  antiseptic  flushings  or  continuous 
antiseptic  irrigation  for  the  purpose  of  minimizing  tension  and  of 
limiting  the  extension  of  the  infection.  In  aseptic  compound  frac- 
tures repair  usually  takes  place  in  the  course  of  time  by  the  forma- 
tion of  an  exuberant  provisional  callus.  Should  callus  formation 
be  unduly  delayed,  several  methods  of  treatment  recommend  them- 
selves to  stimulate  the  process  of  repair.  If  the  wound  has  healed, 
the  fragments  can  be  rubbed  together  (Celsus),  or  the  ends  of  the 
bone  are  drilled,  according  to  the  method  devised  and  extensively 
practised  with  success  by  Brainard.  Steel,  ivory,  and  bone  nails 
have  been  driven  into  the  ends  of  the  fragments  for  the  same  pur- 
pose by  Dieffenbach.  Stimulating  injections  between  and  around 
the  fragments  have  likewise  proved  valuable  in  such  cases.  Of 
these,  a  lo  per  cent,  solution  of  chlorid  of  zinc  (Lannelongue),  in- 
jected in  quantities  of  from  fifteen  to  twenty-five  drops,  is  the  most 
reliable.  If  the  wound  remain  open  and  the  fragments  are  accessi- 
ble, a  tampon  saturated  with  turpentine  has  been  recommended  by 
Mitchell  Banks.  Partial  elastic  constriction  above  the  seat  of  frac- 
ture, as  recommended  by  Dumreicher  and  Helferich,  has  a  decided 
influence  in  stimulating  the  reparative  process.  Finally,  the  use  of 
the  limb,  properly  immobilized,  is  conducive  to  callus  formation  in 
the  treatment  of  delayed  union. 

If  a  false  joint  develop  at  the  seat  of  fracture  in  spite  of  the 
measures  employed,  direct  operative  treatment  should  be  resorted 
to  promptly,  if  the  general  condition  furnishes  no  contraindication. 
The  operation  consists  in  transforming,  by  incision  and  vivifying 
the  fragments,  an  old  into  a  recent  fracture,  and  in  resorting  to 
direct  means  of  fixation  by  suturing,  nailing,  or  by  the  use  of 
intra-osseous  splints,  bone  ferrules,  or  clamps.  After  any  of  these 
operations  the  limb  must  be  properly  immobilized  by  an  efficient 
external  mechanical  support,  and  its  use  recommended  as  soon  as 
the  external  wound  has  healed.  In  vivifying  the  fractured  ends,  as 
little  of  the  bone  should  be  sacrificed  as  possible,  and  the  sections 
made  with  a  view  to  securing  as  large  surfaces  as  possible  for  ap- 
proximation. The  bone-ends  should  never  be  cut  transversely,  as 
such  a  procedure  necessitates  an  unnecessary  loss  of  bone  and  fur- 
nishes only  limited  approximating  surfaces.  The  bone  sections 
should  be  made  obliquely,  so  that  the  -fragments  overlap  each  other 
freely,  when  they  are  immobilized  by  a  bone  or  an  ivory  nail,  a 
means  of  fixation  applicable  also  when  the  vivifying  is  done  by  step 
sections,  as  advised  by  Volkmann,  or  when  the  fragments  are  dove- 
tailed. If  the  bone  defect  is  such  as  to  preclude  the  possibility  of 
direct  fixation,  some  kind  of  an  autoplastic  operation  will  become 


REPAIR    OF    COMPOUND    FRACTURES. 


565 


necessary  to  supply  the  seat  of  fracture  with  a  sufficiency  of  bone- 
producing  tissue  to  effect  restoration  of  the  continuity  of  the  bone. 
Implantation  of  bone  from  any  of  the  lower  animals  has  not  proved 
successful  in  such  cases,  and  further  experimentation  in  this  direc- 
tion is  unwarranted  in  the  light  of  the  experiences  of  the  past. 
Transplantation  of  bone  from  one  human  being  to  another  has  oc- 
casionally proved  successful,  but  the  supply  of  desirable  tissue  is 
always  difficult  to  obtain,  and  the  results  are  much  more  uncertain 
than  those  of  autoplastic  operations.  If  traumatic  osteomyelitis 
complicates  the  case,  the  reparative  process  is  always  retarded,  and 
the  subsequent  sequestration  not  infrequently  results  in  bone  defects 
sufficiently  ex- 
tensive to  pre- 
vent union  by 
bony  consolida- 
tion. This  result 
is  more  likely  to 
occur  if  the  peri- 
osteum is  de- 
stroyed to  any 
considerable  ex- 
tent by  the  sec- 
ondary suppura- 
tive periosteitis, 
and  by  exten- 
sive paraosteal 
phlegmonous  in- 
flammation. It 
is  the  character 
of  the  osteomye- 
litis and  the  ex- 
tent of  the  phleg- 
monous inflam- 
mation that  de- 
termine the  de- 
gree of  danger 
to  limb  and  life 

in  such  cases.  In  the  most  virulent  cases  streptococci  are  almost 
constantly  found  in  the  inflannnatory  product,  and  when  emphysema 
makes  its  appearance,  the  existence  of  a  mixed  infection  can  safely 
be  assumed.  In  the  most  acute  and  dangerous  form  of  wound  in- 
fection the  fractured  limb  becomes  enormously  swollen  and  often 
emphysematous,  and  a  superficial  inflammatory  blush  plainly  in- 
dicates strejjtococcus  infection.  The  general  symptoms  set  in 
quickly,  and  in  a  short  time  reach  a  degree  that  can  leave  no  doubt 
as  to  the  existence  of  progressive  sepsis.  It  is  under  such  circum- 
.stances  that  the  surgeon  is  often  in  doubt  as  to  what  course  he 
should  pursue.      Prompt  action  is  necessary  to  cut  off  the   further 


Fig.  372. — Apparatus  for  permanent  antiseptic  irrigation. 


566 


COMPOUND    FRACTURES. 


supply  of  septic  material,  either  by  free  drainage  and  permanent 
antiseptic  irrigation  or  by  secondary  amputation.  Careful  examina- 
tion and  good  judgment  are  necessary  to  choose  wisely  between  a 
conservative  course  of  treatment  and  a  mutilating  operation.  Each 
case  must  be  judged  on  its  own  merits.  The  appearance  of  gan- 
grene in  the  wound,  or  at  a  distance  from  it,  and  extensive  emphy- 
sema are  conditions  that  warrant  a  resort  to  amputation  as  the  only 
means  of  preventing  death  from  septicopyemia.  Peripheral  evi- 
dences of  extensive  septic  thrombophlebitis  indicate  the  same 
course  as  well  as  the  symptoms  which  point  to  an  incipient  pyemia. 

On  the  other  hand,  extensive 
phlegmonous  inflammation  can  • 
often  be  treated  successfully  by 
free  drainage  and  continued  anti- 
septic irrigation,  with  the  limb 
properly  immobilized  and  sus- 
pended. Drainage,  to  be  effective, 
must  be  thorough.  The  seat  of 
fracture  must  be  exposed,  the 
necessary  debridement  made,  and 
from  the  fracture  the  drainage 
canals  made  by  tunneling  the  tis- 
sues with  a  locked  pair  of  hemo- 
static forceps  of  the  requisite  size 
from  within  outward,  and  the  knife 
used  only  in  making  the  counter- 
opening  at  the  base  of  the  pro- 
jecting cone  of  skin  over  the  point 
of  the  instrument.  The  tubular 
drains  must  be  well  fenestrated 
and  of  adequate  size.  Every  re- 
cess of  the  suppurating  cavity 
must  be  drained  separately  in  a 
direction  that  will  favor  the  ready 
discharge  of  its  contents.  Con- 
tinuous irrigation  should  be  made 
through  several  or  all  the  drains, 
so  that  the  septic  material  that  is  formed  is  promptly  washed  away. 
The  immobilization  of  fractures  thus  complicated  Avill  tax  the 
surgeon's  mechanical  ingenuity  to  the  highest  degree.  One  of  the 
essential  conditions  of  the  mechanical  treatment  consists  in  suspen- 
sion of  the  fractured  limb.  Frequent  change  of  the  fixation  splint 
not  only  causes  unnecessary  pain,  but  never  fails  to  aggravate 
the  existing  inflammation  and  to  inhibit  incipient  reparative  pro- 
cesses. The  surgeon  must  devote  the  necessary  time  and  exercise 
the  requisite  skill  to  apply  a  fixation  dressing  that  will  require  no 
change  until  the  inflammatory  process  is  under  control  and  the 
swelling  has  subsided.      Some  form  of  a  bracketed  plastic  splint  is 


Fig.  373. — Roser's  dilator  for  establish 
ing  drainage  :  a,  Closed  ;  b,  open. 


REPAIR    OF    COMPOUND    FRACTURES. 


567 


best  adapted  to  meet  the  mechanical  indications,  and,  if  required, 
this  method  of  fixation  can  be  combined  with  extension.     Persistent 
efforts   during  a  long  struggle  for  limb  and  life  are  often   rewarded 
ultimately   by  a 
satisfactory  pro- 
cess    of     repair 

and       a        good  Fig.  374.— Sharp  spoon. 

functional  re- 
sult. Early  operative  interference  for  the  osteomyelitic  complica- 
tion is  always  contraindicated.  Early  operations  would  tend  rather 
to  increase  than  diminish  the  danger  from  sepsis,  and  almost  always 
result  in  pseudarthrosis.  If  the  case  yields  to  the  conservative 
measures  employed,  the  inflammatory  process  becomes  limited, 
suppuration  diminishes,  the  fever  subsides,  and  in  the  immediate 
vicinity  of  the  infected  territory  a  process  of  repair  is  initiated. 
Under  favorable  circumstances  the  periosteum  and  medullary  tissue 
assume  active  tissue  formation,  a  profuse  provisional   callus  makes 


^*'&-  375- — fenestrated  rubber  drain. 


Fig.  376. — Lister's  drainage  forceps. 

its  appearance  and  connects,  bridge-like,  the  fractured  ends,  and 
constitutes  a  more  or  less  complete  involucrum  for  the  sequestrat- 
ing bone.  The  external  wounds  heal,  with  the  exception  of  one  or 
more  fistulous  tracts  that  lead  down  to  the  necrosed  bone.  Opera- 
tive interference  must  be  postponed  until  the  fracture  has  united  by  a 
bony  callus,  and  until  the  necrosed  bone  has  become  detached  in  the 
form  of  a  sequestrum  or  sequestra,  when  necrotomy  is  performed  in 
the  usual  manner.  The  healing  of  such  bone  cavities  is  often  a 
very  tedious  process.  The  process  of  final  repair  can  be  hastened 
and  the  functional  result  improved  by  packing  the  cavity,  previously 


568  DISLOCATIONS. 

rendered  aseptic,  with  decalcified  iodoformized  bone  chips.  The 
success  of  this  procedure  depends  entirely  on  the  thoroughness  with 
which  the  disinfection  is  made.  It  is  necessary  to  remove  not 
only  the  necrosed  bone,  but  also  the  infected  granulations  lining 
the  bone  cavity  and  the  fistulous  tracts,  by  the  vigorous  use  of  a 
sharp  spoon,  after  which  the  cavity  and  the  whole  wound  are  dis- 
infected by  pouring  into  them  peroxid  of  hydrogen,  and  later  by  a 
prolonged  irrigation  with  a  hot  2^  per  cent,  solution  of  carbolic 
acid.  The  cavity  is  then  mopped  out  with  a  gauze  sponge,  held  in  the 
grasp  of  a  hemostatic  forceps,  when  it  is  properly  prepared  for  the 
implantation  of  the  decalcified  bone  chips.  In  opening  the  involu- 
crum  the  periosteum  is  carefully  preserved,  and  after  tamponing  the 
cavity  with  the  absorbable  material,  it  is  sutured  over  the  cavity  by  a 
row  of  buried  absorbable  sutures,  when  the  external  wound  is  closed 
in  the  usual  manner,  leaving  a  small  space  at  one  of  its  angles  for 
a  small  absorbable  capillary  drain  consisting  of  a  bundle  of  catgut. 
The  limb  must  be  kept  in  an  elevated  position,  at  an  angle  of  45  de- 
grees, for  at  least  twelve  hours,  to  prevent  undue  parenchymatous 
oozing,  and  immobilization  must  be  continued  until  the  external 
wound  has  healed.  The  patient  must  be  made  to  understand  that 
a  bone  that  has  once  been  the  seat  of  osteomyelitis  remains  pre- 
disposed to  recurrent  attacks  of  limited  extent  for  the  remainder  of 
his  or  her  lifetime. 


CHAPTER  XII. 
DISLOCATIONS, 


A  DISLOCATION  is  a  lateral  separation  between  two  articular  sur- 
faces, complete  or  incomplete.  A  traumatic  dislocation  is  an  injury 
of  a  joint  or  articulating  surfaces,  caused  by  tearing  of  the  hga- 
mentous  connections  and  displacement  of  the  articulating  surfaces 
by  the  dislocating  force.  A  pathologic  dislocation  takes  place 
gradually  by  muscular  contraction  in  joints  made  defective  by  dis- 
ease of  the  ligaments  or  destruction  of  the  articular  ends.  Partial 
or  incomplete  dislocation  is  common  in  pathologic  dislocations, 
but  very  unusual  in  traumatic  dislocations.  A  compound  dislo- 
cation, like  a  compound  fracture,  is  complicated  by  the  existence 
of  a  wound  that  establishes  a  communication  with  the  surface  of  the 
skin  and  the  dislocated  bone.  Bilateral,  double,  and  multiple  dis- 
locations are  designations  used  in  the  same  sense  as  in  the  descrip- 
tion of  fractures.  Besides  traumatic  and  pathologic  dislocations, 
we  speak  of  congenital  dislocations  when  the  displacement  of  the 
articular  surfaces  takes  place  during  intra-uterine  life  in  consequence 
of  defective  development  of  the  articular  ends  or  facets. 

The  nomenclature  of  dislocations  has  reference  to  the  dislocated 


ETIOLOGY    AND    MECHANISM.  569 

member.  Thus,  in  dislocation  of  the  knee-joint,  when  we  speak  of 
an  anterior,  a  posterior,  or  a  lateral  dislocation,  we  have  reference 
to  dislocation  of  the  head  of  the  tibia  in  the  respective  directions. 
The  name  of  the  joint  is  also  usually  associated  with  the  designation 
of  the  dislocation,  and  we  find  that  the  text-books  make  use  of  this 
classification  in  the  description  of  the  different  dislocations.  The 
direction  of  the  dislocation  of  the  distal  member  is  made  use  of  in 
the  anatomic  description  of  the  injury,  and  we  are  made  familiar 
with  the  expressions  anterior,  lateral,  and  posterior  dislocations  of 
the  knee-  and  elbow-joints  ;  dislocation  of  the  head  of  the  humerus 
forward  into  the  subcoracoid  space,  downward  into  the  axilla,  and 
backward ;  and  of  the  head  of  the  femur  upward  and  backward 
upon  the  dorsum  of  the  ilium ;  anteriorly,  posteriorly  into  the 
sciatic  notch,  and  downward  into  the  obturator  foramen. 

Dislocations  occur  much  less  frequently  than  fractures,  the  pro- 
portion being  about  one  to  ten.  This  disproportion  in  the  frequency 
of  fractures  as  compared  with  dislocations  has  an  important  bearing 
on  the  diagnosis  of  injuries  of  the  important  joints,  as  in  cases  of 
doubt  the  existence  of  a  fracture  must  at  least  be  suspected.  Dis- 
locations of  the  shoulder-joint  are  prominent  in  the  statistics,  being 
followed  very  closely  by  dislocations  of  the  elbow-joint.  The  lower 
extremity  is  the  most  frequent  seat  of  fracture,  the  upper,  of  dis- 
locations. Dislocations  of  the  shoiddcr-joint  constitute  about  from 
one-half  to  two-thirds  of  all  dislocations. 

Age  has  an  important  bearing  on  the  etiology  and  location  of 
dislocations.  This  accident  may  occur  at  any  age,  but  is  most  fre- 
quent between  the  ages  of  twenty  and  thirty  years — that  is,  a  period 
of  life  exposed  to  the  greatest  risks  of  all  kinds  of  traumatism.  The 
relative  frequency  of  this  accident  is  greatest  between  forty  and  sev- 
enty years.  In  persons  less  than  twenty  years  of  age  dislocations 
of  the  shoulder  are  rare  ;  on  the  other  hand,  dislocations  of  the 
elbow,  frequent.     The  reverse  is  the  case  during  later  life. 

Etiology  and  Mechanism. — Among  the  predisposing  causes 
must  be  included  the  anatomic  and  pathologic.  The  anatomic  pre- 
disposing causes  consist  in  the  conformation  of  joints  and  deviation 
of  the  axis  of  the  distal  member.  The  shoulder-joint,  owing  to  its 
anatomic  conformation,  is  highly  predisposed  to  dislocation,  and  this 
accounts  quite  satisfactorily  for  the  very  unusual  frequency  with 
which  we  find  dislocations  here  as  compared  with  any  other  of  the 
important  joints.  Deviation  of  the  axis  of  the  distal  member  as  an 
ctiologic  factor  is  best  shown  by  the  frequency  with  which  disloca- 
tions occur  at  the  elbow-joint.  The  deviation  of  the  forearm  out- 
ward from  the  axis  of  the  humerus  constitutes  a  potent  predisposing 
cause  of  dislocations  of  this  joint. 

Among  the  pathologic  prcdisi)osing  causes  must  be  mentioned 
distention  of  joints  by  effusion  or  extravasation,  destruction  or  soft- 
ening of  the  hgamcnts,  and  fractures  involving  joints  or  their  vicin- 
ity.    The  stretching  and  weakening  of  ligaments  consequent  upon 


S70 


DISLOCATIONS. 


prolonged  intra-articular  tension  is  one  of  the  most  potent  predis- 
posing causes  of  pathologic  dislocation.  The  softening  and  destruc- 
tion of  ligaments  resulting  from  chronic  and  acute  diseases  of 
joints  act  in  a  similar  manner.  The  frequency  with  which  dislo- 
cations of  large  joints  are  complicated  by  fracture  reminds  us  of  the 
influence  of  fractures  as  a  predisposing  cause  of  dislocation.  Frac- 
ture of  the  upper  and  posterior  margin  of  the  acetabulum,  if  suffi- 
ciently deep  and  extensive,  removes  the  support  for  the  head  of  the 
femur.     This  complication  is  to  be  suspected  in  dislocations  of  the 


Fig.  377- — Fracture  of  the  upper  rim  of  the  acetabulum,  with  partial  dislocation  of  the 
head  of  the  femur  upward. 

hip-joint  in  which  the  reduction  can  be  made  without  any  difficulty, 
but  is  followed  almost  immediately  by  recurrence  of  the  dislocation. 

Dislocations  of  the  elbow-joint  are  most  frequently  associated 
with  fracture,  and  it  is  here  that  the  fracture  is  so  often  overlooked 
and  consequently  the  dislocation  imperfectly  reduced,  or,  if  reduced, 
followed  by  partial  or  complete  recurrence,  owing  to  defective  treat- 
ment of  the  fracture.  These  are  the  cases  that  demand  a  most 
searching  examination  under  the  influence  of  an  anesthetic,  and  the 
most  untiring  attention  during  the  entire  treatment. 

The  exciting  causes  of  dislocations  are  external  violence,  applied 


PATHOLOGY    OF    RECENT    DISLOCATIONS. 


571 


either  directly  at  the  seat  of  dislocations  or  at  some  distance,  the 
indirect  force  being  transmitted  through  the  axis  of  the  bone,  and 
muscular  action.  By  far  the  greatest  number  of  dislocations  are 
produced  by  indirect  force.  Dislocations  from  muscular  contrac- 
tion are  rare  in  intact  joints,  and  are  seen  most  frequently  in  habitual 
dislocations  where  the  joint  surfaces  and  ligamentous  connections 
have  been  damaged  by  antecedent  disease  or  injury. 

Pathology  of  Recent  Dislocations. — One  of  the  constant 
pathologic  conditions  in  every  dislocation  is  more  or  less  tearing 
of  the  ligamentous  connections.  A  dislocation  can  never  occur 
short  of  some  laceration  of  the 
soft  structures  that  hold  the  ar- 
ticular surfaces  in  contact.  In 
pathologic,  congenital,  and  hab- 
itual dislocations  the  defects  of 
the  joint  surfaces  or  destruction 
or  relaxation  of  the  ligaments 
furnish  the  predisposing  cause, 
and  permit  a  dislocation  to  occur 
in  consequence  of  a  very  slight 
trauma,  or  as  the  result  of  mus- 
cular contraction.  /;/  ball-and- 
socket  joints  laceration  of  the  liga- 
ments is  found  on  the  side  of  the 
dislocation,  and  the  untorn  part 
of  the  ligaments  fixes  the  dislo- 
cated bone  firmly  in  its  abnormal 
position,  and  offers  the  greatest 
opposition  to  efforts  at  reduction. 
In  dislocations  of  the  upper  ar- 
ticular ends  of  the  humerus  and 
femur  the  head  of  the  bone  often 
escapes  through  a  slit  or  rent  in 
the  capsule,  when  the  neck  of 
the  bone  is  grasped  by  the  mar- 
gins of  the  tear,  a  condition  that 
often  effectively  resists  all  efforts 
at  reduction.      It  may  be  .stated, 

as  a  rule,  that  reduction  is  easy  in  proportion  to  the  extent  of  tear- 
ing of  the  ligaments,  and  very  difficult  and  occasionally  impossible 
when  tlie  capsule  retains,  to  a  maximum  degree,  its  resisting  power. 
Physicians  must  learn  to  appreciate  the  practical  importance  of  over- 
coming the  resistance  of  the  untorn  portion  of  the  ligaments  in  at- 
tempting reduction,  to  antagonize  the  most  serious  mechanical  resis- 
tance by  placing  the  dislocated  bone  in  the  exact  position  that  it  occupied 
the  moment  the  dislocation  occurred,  which  zvill  akvays  result  in  re- 
laxation of  the  untorn  portion  of  the  ligament.  In  all  joints  other 
than  enarthrodial  the  ligaments  on  one  or  both  sides  are  ruptured. 


Fig.  378. — Anterior  dislocation  of  the 
head  of   the  radius,   with    fracture  of   the 

uhia. 


■572 


DISLOCATIONS. 


In  dislocations  of  the  lower  maxilla  the  ligaments  are  stretched 
and  partially  torn  ;  the  same  may  be  the  case  in  joints  supplied 
with  relaxed  ligaments.  Not  enough  stress  has  been  placed  on 
the  tearing  of  ligaments  in  the  reduction  of  dislocations.  It  is  an 
injury  which,  if  not  recognized  and  properly  treated,  only  too  often 
weakens  the  joint  permanently,  and  lays  the  foundation  for  habitual 
dislocations.  After  reduction  has  been  effected,  the  treatment  must 
be  directed  toward  a  satisfactory  repair  of  the  injured  capsule,  to 
restore  its  normal  efficiency  as  a  retentive  apparatus.  Premature 
active  and  passive  motion  interferes  with  ideal  healing  of  the  joint 

wound,  and  should  be  carefully 
avoided  until  the  healing  process 
is  completed — that  is,  in  the  case 
of  the  large  joints  ;  rest,  with  the 
limb  in  the  most  favorable  posi- 
tion to  relax  the  torn  part  of  the 
capsular  ligament,  must  be  en- 
forced for  from  three  to  four 
weeks.  Enforced  rest  beyond  this 
time  may  again  result  in  hernia, 
by  causing  inactivity  atrophy. 

Rupture  of  tendons  and  mus- 
cles is  another  important  feature 
in  the  pathology  of  recent  dislo- 
cations. The  extent  to  which 
muscular  action  is  restored  im- 
mediately after  the  reduction  will 
serve  to  indicate,  to  some  degree 
at  least,  the  presence  and  extent 
of  this  part  of  the  inj  ury .  Fixa- 
tion of  the  limb,  with  the  injured 
tendon  or  muscle  relaxed,  con- 
tinued until  union  is  firm  enough 
to  warrant  the  removal  of  the 
mechanical  support,  is  a  very 
important  part  of  the  treatment 
in  such  cases. 

The  splitting  off  by  traction 
force  of  portions  of  the  rim  of  the 
acetabulum,  of  the  glenoid  cavity,  the  margins  of  the  malleoli,  and 
the  condyles  of  the  femur  and  humerus  takes  place  much  more 
frequently  in  dislocations  than  is  generally  supposed,  and  is  often 
responsible  for  unsatisfactory  functional  results,  and  may  furnish  a 
serious  obstacle  to  reduction,  and  often  becomes  the  direct  cause 
of  habitual  dislocation.  The  chipping  off  of  subcutaneous  bony 
prominences  can  usually  be  discovered  by  careful  palpation,  as 
crepitus  can  be  elicited  by  rubbing  the  fractured  surfaces  together ; 
but  in  hip-  and  shoulder-joint  dislocations  this  method  of  examina- 


Fig.  379. — Dislocation  of  both  bones 
of  the  forearm  backward,  with  fracture  of 
the  internal  epicondyle  of  the  humerus. 
Epicondyle  is  displaced  downward  and 
backward. 


PATHOLOGY    OF    RECENT    DISLOCATIONS.  S73 

tion  will  not  succeed  in  demonstrating  the  presence  or  absence  of 
this  very  important  complication.  It  may,  however,  be  suspected 
if  the  reduction  is  made  with  unusual  ease  or  if  it  is  attended  by 
any  especial  difficulties,  and  more  particularly  if  redislocation 
occurs  by  placing  the  limb  in  the  same  position  it  occupied  the 
moment  the  accident  occurred.  Crepitation  during  the  reduction  and 
redislocation  is  seldom  felt,  and  can  not  be  relied  upon  in  diagnosti- 
cating a  marginal  fracture  of  any  of  the  deep  joints.  The  exis- 
tence of  such  a  complication  calls  for  prolonged  immobilization  of 
the  joint  after  the  reduction.  Bony  union  between  the  fractured 
surfaces  is  seldom  obtained,  even  under  the  most  careful  treatment, 
but  if  the  fragment  unites  by  the  formation  of  a  short  and  strong 
fibrous  union,  the  function  and  strength  of  the  joint  are  not  neces- 
sarily permanently  impaired  by  the  fracture. 

Every  dislocation  is  attended  by  injuries  of  the  ligaments  and 
para-articular  tissues,  constituting  a  severe  sprain,  which  must  be 
properly  treated  after  reduction  has  been  made.  Such  reduction 
must  be  accomplished  in  a  manner  that  is  calculated  not  to  add 
unnecessarily  to  the  size  of  the  first  wound.  The  amount  of  extra- 
vasation depends  on  the  extent  of  the  injury  to  the  capsule  and 
other  soft  tissues.  Intra-articular  and  para-articular  hemorrhage 
increases  the  primary  swelling  caused  by  the  dislocated  bone,  but 
its  extent  can  not  be  estimated  with  any  degree  of  accuracy  before 
the  reduction.  The  swelling  that  remains  after  the  reduction  of  a 
recent  dislocation  consists  of  extravasated  blood,  the  presence  of 
which  can  later  be  recognized  by  the  appearance  of  ecchymosis. 
If  the  primary  swelling  from  this  cause  is  large,  it  often  obscures 
important  landmarks  upon  which  the  physician  has  to  rely  so  much 
in  recognizing  the  dislocation  and  in  satisfying  himself  that  reduc- 
tion has  been  effected.  Secondary  swelling  setting  in  a  few  hours 
after  reduction  is  due  to  effusion  from  the  injured  capsule  and 
synovial  membrane. 

In  some  instances  the  dislocating  force  is  productive  of  a  frac- 
ture at  the  same  time,  the  dislocation  of  what  remains  of  the  head 
of  the  bone  taking  place  after  the  fracture  has  occurred.  In  the 
event  of  such  an  injury  the  dislocated  bone  is  not  immobilized  to 
the  same  extent  as  when  the  entire  articular  end  has  become  dis- 
placed, because  the  complicated  injury  implies  extensive  tearing  of 
the  capsule  of  the  joint  and  a  diminution  in  size  of  the  articular 
end. 

Fracture  of  the  articular  end  of  the  bone  is  rare,  and  when  it 
does  occur,  it  is  produced  after  the  dislocation  has  occurred,  and 
usually  by  a  continuation  of  the  force  that  caused  the  dislocation — 
that  is,  it  is  a  secondary  accident.  Partial  fracture  of  the  rim  of 
the  .socket  in  enarthrodial  joints  and  evulsion  of  portions  of  the 
cjjiphyses  as  complicating  injuries  are  not  rare,  and  often  constitute 
the  principal  causes  of  unsatisfactory  restoration  of  function  after 
perfect  reduction  and  otherwise  efficient  treatment. 


574 


DISLOCATIONS. 


Ruptures  of  important  vessels  and  nerves  are  the  most  serious 
complications  of  dislocations.  These  accidents  are,  fortunately, 
rare,  and  when  they  do  occur,  they  have  been  produced  by  trac- 
tion or  twisting  after  the  dislocation  has  taken  place.  Rupture  of 
the  axillary  artery  or  any  of  the  large  branches  is  an  accident  to 
be  feared  and  guarded  against  in  attempting  the  reduction  of  old 
dislocations  of  the  shoulder-joint.  This  accident  has  occurred 
repeatedly  during  such  attempts,  and  has  only  too  often  been  fol- 
lowed by  gangrene  or  the  formation  of  a  traumatic  aneurysm.  In 
using  more  than  ordinary  force  in  attempting  the  reduction  of  a  recent 
or  old  dislocation  the  relation  of  large  blood-vessels  and  nerves  to  the 
dislocated  borie  must  be  carefully  studied,  and  all  harmful  traction 
on  these  important  structures  studiously  avoided.  The  anterior  cir- 
cumflex nerve  is  occasionally  torn  by  the  dislocating  force  or  by 
the  attempts  to  reduce  a  dislocation  of  the  shoulder-joint.  Such 
an  accident  is  necessarily  followed  by  permanent  paralysis  of  the 
deltoid  muscle.  Inflammatory  adhesions  and  the  great  force 
exerted  by  using  the  dislocated  bone  as  a  lever  will  occasionally 
produce  a  disastrous  result  when  least  expected. 

After  reduction  has  been  made  successfully,  the  objective  and 
subjective  symptoms  are  remedied  promptly,  and  the  subcutaneous 
injury,  as  a  rule,  is  repaired  quickly  and  satisfactorily,  provided  the 
injured  parts  are  kept  in  a  condition  of  rest  a  sufficient  length  of 
time.  In  some  cases,  however,  perfect  repair  fails  to  obtain,  owing 
to  the  extent  of  the  injury  of  the  soft  tissues,  the  margins  of  the 
articular  surfaces,  injury  to  important  tendons,  muscles,  and  nerves, 
the  amount  of  extravasation,  and,  later,  effusion  into  the  injured 
joint,  and  the  development  later  of  joint  affections  arising  from  the 
trauma.  Active  and  passive  motion,  massage,  and  electricity  at  the 
expiration  of  three  or  four  weeks  after  the  injury  are  the  most  use- 
ful therapeutic  resources  in  removing  stiffness,  in  preventing  anky- 
losis, and  in  restoring  the  normal  range  of  motion  and  usefulness 
of  the  joint. 

Unreduced  dislocations  are  not  infrequently  met  in  neglected 
cases  and  as  the  result  of  erroneous  diagnosis,  impossibility  of 
effecting  reduction  in  recent  cases,  and  sometimes  as  an  unavoidable 
consequence  of  dislocation  complicated  by  fracture. 

The  terms  recent  and  old  or  ancient  dislocations  are  relative  in 
their  clinical  meaning.  Some  dislocations  become  old — that  is, 
irreducible — in  a  few  days  or  weeks  ;  others  can  be  successfully 
reduced  by  the  bloodless  method  a  year  or  more  after  the  accident. 
Of  eight  or  ten  cases  which  have  come  under  my  own  care,  it  has 
been  my  good  fortune  never  to  have  failed  in  reducing  a  disloca- 
tion of  the  shoulder-joint  three  months  old,  while  I  failed  in  two 
cases  of  dislocation  of  the  hip-joint  after  about  the  same  lapse  of 
time.  From  a  trying  experience  every  surgeon  has  become  aware 
of  the  fact  that  dislocations  of  the  elbow-joint  in  any  direction  and 
in  all  anatomic  forms  become  irreducible  in  a  very  short  time.      The 


SYMPTOMS. 


575 


head  of  the  dislocated  bone  in  an  old  irreducible  dislocation  soon 
becomes  encapsulated,  and  if  it  presses  against  a  bone  surface  and 
a  certain  degree  of  motion  is  preserved,  a  new  socket  forms  and  the 
limb  becomes  useful  in  proportion  to  the  range  of  motion.  One  of 
the  obstacles  to  successful  reduction  of  an  old  dislocation  is  union 
of  the  untorn  portion  of  the  capsule  with  the  cavity  of  the  joint. 
Interposition  of  the  torn  portion  of  the  capsule  between  the  head 
of  the  dislocated  bone  and  the  cavnty  of  the  joint  imposes  another 
serious  impediment  to  reduction.  The  encapsulation  of  the  head 
of  the  dislocated  bone  in  its  abnormal  position,  and  adhesions  of  the 
neighboring  socket,  nerves,  and  blood-vessels,  add  to  the  difficulties 
and  immediate  risk  of  forcible  attempts  at  reduction.  One  of  the 
almost  hopeless  conditions,  so 
far  as  successful  reduction  and 
restoration  of  function  are 
concerned,  is  furnished  by  a 
gradual  but  progressive  ob- 
literation of  the  cavity  of  the 
joint.  This  remote  patho- 
logic condition  is  established 
by  shrinkage  of  the  capsule — 
filling  in  of  the  cavity  by  new 
material  and  shallowing  of  the 
articular  depression  by  atrophy 
of  its  rim. 

Symptoms.  —  The  most 
important  distinguishing  fea- 
tures between  a  nonimpacted 
fracture  and  a  dislocation  are 
a  false  point  of  motion  and 
preternatural  mobility  in  the 
former,  while  in  the  latter 
motion  is  either  entirely  sus- 
pended or  at  least  greatly  im- 
paired by  the  displacement  of 
the  bone,  held  firmly  in  its  ab- 
normal position  by  the  untorn  portion  of  the  capsule,  muscles,  ten- 
dons, and  fascia,  changed  in  their  relations  to  the  dislocated  bone  by 
the  alterations  in  their  point  of  origin  and  insertion.  The  deformity 
that  attends  a  dislocation  is  usually  more  striking  and  of  greater 
diagnostic  value  than  in  fractures  (Figs.  381  and  382).  In  dis- 
locations the  niaxinium  degree  of  deformity  is  seen  immediately  after 
the  accident  has  occurred,  while  in  fractures  it  is  increased  by  nmscidar 
contraction  and  the  zveight  of  the  limb.  In  dislocation  the  deformity 
is  caused  by  the  head  of  the  dislocated  bone  being  removed  from  its 
socket  by  the  dislocating  force,  and  remainiftg  fixed  and  nninjlnenced 
later  by  the  position  of  the  body  or  limb.  Deformitj'  as  an  indication  of 
the  existence  of  a  dislocation  presents  itself  to  greatest  diagnostic 


Fig.  380. — Old  di-?liji_ati')ii  of  the  femur  with 
very  complete  new  acetabulum  (Kronlein). 


576 


DISLOCATIONS. 


advantage  immediately  after  the  injury  has  been  received,  and  before 
important  anatomic  landmarks  become  obscured  by  the  extravasa- 
tion of  blood  from  the  torn  soft  parts. 

Deformity  is  frequently  so  well  marked  and  characteristic  as 
to  be  almost  diagnostic.  In  posterior  dislocation  of  both  bones 
of  the  forearm,  the  anteroposterior  diameter  of  the  limb  at  a 
point  corresponding  with  the  condyles  of  the  humerus  is  greatly 
increased,  the  limb  is  in  a  fixed  extended  position,  and  the  tip  of  the 
olecranon  process  is  seen  and  felt  above  its  normal  level.  In 
dislocation  of  the  head  of  the  femur  upon  the  dorsum  of  the 
ilium  the  marked  prominence  of  the  head  of  the  femur  in  its  abnor- 
mal position  at  once  attracts  attention,  and  the  thigh  is  found 
adducted,  rotated  inward,  and  the  limb  markedly  shortened.  In  a 
subcoracoid  dislocation  of  the  head  of  the  humerus  the  acromion 


Fig-   381- — Complete  posterior  dislocation  of  the  head  of  the  tibia  (Hoffa). 


process  is  preternaturally  prominent,  the  depression  below  it  con- 
spicuous, the  humerus   abducted  and  immovable, .  and   the   space 
•below  the  coracoid  process  of  the  scapula  made  prominent  by  the 
displaced  head  of  the  humerus. 

In  rendering  the  deformity  a  reliable  witness  of  dislocation,  the 
examination  must  be  made  with  the  necessaiy  care.  Comparison 
between  the  same  joints  is  necessary  to  detect  and  note  abnormalities. 
The  removal  of  clothing  to  the  requisite  extent  must  precede  inspec- 
tion, palpation,  and  mensuration,  as  well  as  to  determine  the  degree 
of  impairment  of  mobility  of  the  injured  limb.  This  advice  may 
appear  trivial  and  unessential,  but  it  should  never  be  lost  sight  of 
in  conducting  the  examination.  The  detection  of  the  head  of  a 
bone  in  an  abnormal  position  after  an  injury  goes  far  in  the  diag- 
nosis of  a  dislocation.      If  we  can,  at  the  same  time,  determine  by 


SYMPTOMS. 


577 


inspection  and  palpation  a  vacancy  in  the  position  usually  occupied 
by  the  head  of  the  bone,  and  a  faulty  axis  of  its  shaft,  we  are  in 
possession  of  additional  valuable  corroborative  evidence.  The  head 
of  the  femur  and  humerus  can  usually  be  detected  in  their  faulty 
position  without  any  special  difficulty,  and  can  be  identified  as  such 
by  rotating  the  shaft  of  the  bone  and  noting  the  faulty  position  of 
its  axis.  The  altered  axis  of  the  shaft  of  the  dislocated  bone  is 
usually  mentioned  as  an  indication  of  dislocation,  but  its  diagnostic 
value  is  not  made  use  of  sufficiently  or  is  underestimated.  Abnormality 
of  the  axis  of  a  long  bone  after  an  vijury  is  a  reliable  indication  of 
the  existence  of  a  dislocation 
or  a  fracture  near  the  ar- 
ticular end.  The  detection 
of  the  head  of  a  bone  in  a 
fa?ilty  position  and  abnor- 
mality of  the  axis  of  the 
shaft,  combined  with  fixation 
of  the  limb,  are  three  proofs 
that  speak  unmistakably  for 
dislocation. 

To  determine  the  exis- 
tence of  deviation  from  nor- 
mal of  a  shaft  of  a  bone  it 
is  not  only  necessary  to  de- 
termine the  abnormal  posi- 
tion of  the  limb,  but  what  is 
gained  from  inspection  must 
also  be  confirmed  by  tracing 
the  direction  of  the  shaft  of 
the  bone  from  end  to  end 
by  careful  palpation,  and  by 
connecting  the  articular  ends 
by  a  straight  line  drawn  with 
a  tape-measure,  string,  or, 
still  better,  by  placing  over 
the  shaft  the  inflexible  rule. 
To  exemplify,  in  subcora- 
coid  dislocation  of  the  head  of  the  humerus  the  faulty  line  of 
the  shaft  of  the  bone  will  not  point  in  the  direction  of  the  glenoid 
cavity,  but  away  from  it  toward  the  coracoid  process  of  the  scapula. 
Fixation  of  the  limb  in  its  abnormal  position  is  one  of  the  constant 
clinical  features  of  a  dislocation,  and  can  mislead  only  in  impacted 
fractures  of  the  articular  ends.  In  impacted  fractures  there  is  less 
deviation  of  the  shaft  of  the  bone,  and  the  mobility  of  the  joint  is 
not  impaired  to  the  .same  extent.  Comparative  mensuration  is 
always  employed  as  a  diagno.stic  resource  in  doubtful  dislocations, 
as  well  as  in  fractures.  As  in  fractures,  fixed  anatomic  landmarks 
are  selected,  and  the  limbs  should  always  be  placed  in  .symmetric 
37 


Fig.  382. — Supracondyloid  fracture  of  the  femur 

(Hoffa). 


578 


DISLOCATIONS. 


position.  With  few  exceptions  shortening  is  always  found.  No 
shortening  would  be  expected  in  dislocations  of  the  head  of  the 
radius  alone.  Elongation  attends  dislocation  of  the  head  of  the 
humerus  and  femur  downward,  but  the  rarity  of  these  accidents, 
compared  with  the  frequency  of  the  more  common  forms  of  disloca- 
tion, does  not  detract  from  the  importance  of  the  rule  that  shorten- 
ing is  an  important  symptom  of  dislocations  as  well  as  of  fractures. 
The  altered  attitude  of  the  limb,  ascertained  by  inspection  and 
confirmed  by  palpation,  aids  us  in  suspecting  the  existence  of  a  dis- 
location.    The   faulty  position  of  the  limb  and  the  restriction  of 

motion  are  due  to  the  new 
relations  of  the  head  of  the 
dislocated  bone  to  the  untorn 
portion  of  the  capsule,  adjacent 
muscles,  tendons,  and  fascia. 

Pain  is  more  severe  than 
in  fractures,  which  can  readily 
be  explained  by  the  greater 
degree  of  harmful  pressure 
and  tension  caused  by  the 
displaced  end  of  the  bone 
than  by  the  ends  of  a  frac- 
ture. The  intense  pain  that 
attends  and  follows  a  disloca- 
tion is  always  an  indication 
of  great  pressure  and  tension, 
caused  by  the  displaced  head 
of  the  bone.  Pain  is  a  dis- 
tressing symptom,  and  is  apt 
to  become  permanent  if  the 
dislocation  is  not  reduced  and 
the  displaced  end  of  the  bone 
makes  compression  of  any 
of  the  large  sensitive  nerve- 
trunks.  It  is  a  marked  symp- 
tom in  dislocation  of  the  head 
of  the  humerus  in  the  direc- 
tion of  the  axillary  plexus. 
In  obscure  cases  and  in  cases  complicated  by  fracture,  the  X-ray 
will  demonstrate  the  existence  or  absence  ^  ^  a  dislocation,  and  if  a 
fracture  exists,  its  location  and  relation  to  the  dislocation. 

Treatment. — It  requires  no  argument  in  pleading  for  an  early, 
correct  diagnosis  and  prompt  reduction  in  all  dislocations.  Pro- 
crastination obscures  the  diagnostic  information,  delays  the  relief, 
and  retards  restoration  of  function.  The  sooner  a  dislocation  is 
recognized,  the  earlier  the  relief;  and  the  sooner  the  reduction  is 
effected,  the  better  the  functional  results.  Doubt  and  hesitation  are 
utterly  out  of  place  here.      If  any  doubt  exists  in  regard  to  the 


c^:^^ 


Fig.  383. — Characteristic  deformity  in  dis 
location  of  the  head  of  the  femur  upon  the  dor 
sum  of  the  ilium  (Hoffa). 


TREATMENT. 


579 


diagnosis,  the  sooner  it  is  cleared  away  by  the  additional  advice  of 
consultants  or  the  use  of  the  Rontgen  ray,  the  better  for  the  wel- 
fare of  the  patient  and  the  reputation  of  tlie  surgeon.  The  malpo- 
sition of  fractures  can  often  be  corrected  weeks  after  the  accident 
without  any  special  detriment  to  the  patient,  but  the  same  can  not 
be  said  of  dislocations.  Unrecognized  and  unreduced  dislocations 
have  been  the  bane  of  many  well-meaning  practitioners.  In  doubt- 
ful cases  all  diagnostic  resources,  including  the  use  of  a  general 
anesthetic  and  the  X-ray,  have  often  been  brought  into  requisition, 
and  if  they  do  not  yield  the  desired  information,  it  is  to  the  credit 


^}ii-  384. — Old  fracture  through  the  surgical  neck  of  the  humerus  mistaken  for  ante- 
rior dislocation.  Marked  displacement  of  lower  fragment  forward  and  inward.  Union 
by  massive  callus  in  malposition.  A  considerable  portion  of  the  callus  mass  was  removed  to 
relieve  pressure  symptoms  (Clinic,  Rush  Medical  College). 

of  the  physician  to  make  the  necessary  open,  honest  admission  and 
request  counsel.  It  is  a  great  mi.stake  to  shoulder  the  burden  of 
an  unknown  weight,  when  relief  is  in  sight  by  calling  in  the  aid  of 
competent  colleagues.  The  most  expert  surgeon  often  finds  him- 
self in  such  a  situation,  and  is  only  too  willing  to  divide  the  respon- 
sibility incident  to  the  case  with  one  or  more  of  his  colleagues.  It 
is  certainly  to  be  expected,  therefore,  that  the  general  practitioner, 
with  fewer  opportunities  for  observation,  would  Idc  more  willing  and 
anxious  to  share  such  responsibility.      There  are  few  things  more 


^80  DISLOCATIONS. 

humiliating  in  surgery  than  to  hve  in  a  community  inhabited  by 
former  patients  with  unrecognized  and  unreduced  dislocations.  The 
error  of  two  or  more  men  in  such  cases  receives  less  blame  from 
juries,  judges,  and  the  public  than  the  mistakes  of  one. 

Positiveness  in  the  diagnosis  must  come  in  advance  of  attempts 
at  treatment.  A  correct  diagnosis  once  made,  prepares  the  way 
for  successful  treatment.  If  the  physician  is  able  to  picture  to  him- 
self correctly  the  manner  in  which  the  injury  tvas  inflicted,  the  exact 
position  of  the  limb  at  the  moment  the  accident  occiirred,  the  location 
of  the  dislocated  head  of  the  bone,  and  its  relations  to  the  structures 
that  antagonize  reduction,  he  zvill  have  very  little  difficulty  indeed  in 
devising  the  manipidations  that  zvill  enable  him  to  effect  reduction.  It 
is  in  such  cases  that  it  is  wise  policy  to  locate  the  resisting  structures 
and  resort  to  the  manoeuvers  to  overcome  them  with  as  little  force 
as  possible.  Blind  action  is  dangerous  in  all  such  cases.  Shrewd 
strategy  is  better  than  force.  Relaxation  is  safer  and  more  effec- 
tive than  tearing  ;  position  more  effectual  than  brutal,  ill-directed 
force.  It  is  said  that  the  late  Professor  Brainard  was  once  called  to 
reduce  a  dislocation  of  the  ankle-joint  of  a  valuable  horse.  He 
made  the  remark  that  if  he  \yere  conversant  with  the  anatomy  of 
the  joint  he  would  have  no  difficulty  in  doing  what  was  necessary, 
but  as  he  was  entirely  innocent  of  such  knowledge,  he  refused  to 
interfere.  This  was  an  honest  confession  on  his  part,  and  did  more 
to  maintain  the  great  reputation  he  enjoyed  as  a  surgeon  than  many 
of  his  brilliant  and  original  operations.  An  intimate  knozvlcdge  of 
the  anatomy  of  the  joints  and  the  points  of  origin  and  insertion  of 
the  muscles  that  antagonize  reduction  is  an  essential  prereqidsite  to 
successfid  surgical  intervention  in  dislocations,  recent  and  ancient.  I 
am  fully  convinced  that  such  information  is  not  always  at  the  dis- 
position of  the  many  practitioners  who  are  called  upon  to  diagnos- 
ticate and  reduce  dislocations.  From  necessity  the  average  student 
prepares  himself  for  his  examination  on  anatomy,  and  after  this 
trying  ordeal  has  been  passed,  he  only  too  often  fails  to  keep 
abreast  of  this  science  in  later  life.  His  shortcomings  in  this 
primary  branch  of  medicine  become  most  apparent  when  he  is 
called  upon  to  diagnosticate  and  reduce  dislocations. 

While,  as  a  rule,  it  is  advisable  to  attempt  reduction  as  soon  as 
possible  after  the  occurrence  of  a  dislocation,  actual  interference 
may  have  to  be  postponed  until  the  patient  recovers  from  the  imme- 
diate effects  of  the  primary  shock  ;  more  especially  is  this  so  if  it 
becomes  necessary  to  make  use  of  a  general  anesthetic.  All 
methods  of  reduction  must  be  based  upon  the  recognition  of  the  obsta- 
cles to  reduction.  Muscular  rigidity  and  contraction  constitute  very 
important  elements  in  the  fixation  of  the  dislocated  limb  in  its 
faulty  position  and  in  antagonizing  the  efforts  at  reduction.  In  dis- 
locations easily  reducible,  muscular  opposition  can  often  be  dimin- 
ished or  entirely  overcome  for  the  moment  required  for  reduction 
by  diverting  the  patient's  attention  ;  when  the  opposition  from  this 


TREATMENT.  58 1 

source  is  great,  it  can  ahva}-s  be  eliminated  by  a  deep  general  anes- 
thesia. The  use  of  a  general  anesthetic  enables  us  not  only  to  de- 
termine with  a  greater  degree  of  accuracy  the  exact  position  of 
the  dislocated  bone,  but  by  removing  muscular  resistance  further 
facilitates  and  simplifies  the  surgeon's  work  in  replacing  the  bone 
in  its  normal  position.  Muscular  relaxation  as  a  preliminary  step 
to  reduction  is  especially  desirable  in  the  reduction  of  dislocated 
joints  that  are  under  the  control  of  powerful  muscles,  as  the  hip- 
and  shoulder-joints,  and  in  persons  of  strong  muscular  develop- 
ment, while  in  emaciated  and  enfeebled  persons,  in  children,  and  in 
the  aged  it  can  often  be  dispensed  with. 

///  all  dislocations  the  iintorn  portion  of  the  capsule  or  ligaments  plays 
an  important  role  in  fixing  the  displaced  bone  in  its  abnormal  position 
and  in  resisting  efforts  at  reduction.  Bigelow  and  Gunn  have  made 
this  obstacle  to  reduction  a  special  study,  and  by  careful  dissections 
have  shown  how  it  can  be  best  overcome.  All  the  different  methods 
of  reduction  by  manipulation  are  based  on  the  noiv  generally  recog- 
nized great  principle  of  moving  the  dislocated  bone  in  such  a  zvay  as 
to  relax  the  uutorn  portion  of  the  capsule  or  ligaments.  This  nde  sJiould 
never  be  transgressed  in  the  reduction  of  a  dislocation  by  either 
manipulation  or  traction.  As  a  rule,  the  untorn  portion  of  the  cap- 
sule is  at  a  point  opposite  the  location  of  the  head  of  the  dislocated 
bone.  There  are,  however,  exceptions  to  this  rule,  as,  for  instance, 
in  dislocations  of  the  shoulder-joint  the  head  of  the  humerus  usually 
finds  its  way  out  of  the  joint  through  a  tear  or  slit  on  the  anterior 
side  of  the  capsule,  but  may  become  subsequently  displaced  into 
the  axillary  space,  or  even  to  a  point  behind  the  glenoid  cavity. 
The  possibility  of  such  an  occurrence  should  be  remembered  when 
the  prescribed  manipulations  fail,  as  a  change  in  the  direction  of  the 
movement  may  accomplish  what  is  so  essential — relaxation  of  the 
untorn  part  of  the  capsule.  If  the  untorn  portion  of  the  capsule  is 
not  respected  in  attempting  the  reposition,  what  remains  of  the  cap- 
sule has  to  be  torn  before  the  bone  can  be  replaced,  thus  adding 
unnecessarily  to  the  injury  of  the  soft  structures  of  the  joint.  If 
the  injured  limb  is  placed  in  the  exact  position  it  occupied  at  the 
moment  the  injury  occurred,  the  untorn  portion  of  the  ligamentous 
connections  will  always  be  relaxed,  and  it  is  in  this  position  that 
neccs.sary  manipulations  sliould  always  be  commenced  and  the 
later  movements  made,  with  s[)ecial  reference  to  maintaining  the 
relaxation. 

Interposition  between  the  head  of  the  dislocated  bone  and  the 
adjoining  cavity  of  a  portion  of  the  ruptured  part  of  the  capsule 
occasionally  constitutes  a  barrier  to  all  bloodless  attempts  at  reduc- 
tion. The  cxi.stence  of  such  a  mechanical  obstruction  is  often  sus- 
pected in  irreducible  luxations,  but  its  actual  presence  can  only  be 
ascertained  by  exposing  the  joint  in  making  the  reduction  by  the 
open  method. 

An  unusual  relation  of  the  dishicatcd  head  of  the  bone  to  certain 


582 


DISLOCATIONS. 


adjoining  muscles  may  interfere  with  successful  reduction.  In  dis- 
location of  the  head  of  the  humerus  forward  the  untorn  portion  of 
the  subscapular  muscle  in  rare  cases  is  interposed  between  the  head 
of  the  humerus  and  the  glenoid  cavity,  frustrating  all  attempts  at  re- 
duction by  the  bloodless  methods.  In  typical  dislocation  the  untorn 
portion  of  the  capsule  always  presents  itself  as  the  most  formidable 
obstacle  to  reduction  ;  in  atypical  luxations  the  ligamentous  connec- 
tions are  torn  so  completely  that  no  opposition  is  encountered  from 
this  source,  in  which  case  the  influence  of  muscle  contraction  and 
bony  prominences  in  the  way  of  an  easy  return  of  the  bone  must  be 
remembered  in  attempting  reposition. 

Reduction  by  manipulation  is  applicable  only  to  typical  dislo- 
cations. Manipidation  in  the  reduction  of  a  dislocation  consists  of  a 
succession  of  gentle  motions  communicated  to  the  dislocated  limb,  by 

which  the  margins  of  the  rent  in  the  cap- 
side  are  separated  from  each  other,  and 
the  head  of  the  bone  is  rolled  back  into 
place  by  aid  of  the  untorn  portion  of  the 
ligaments. 

The  mechanism  and  technic  of  man- 
ipulation, as  employed  in  the  reduction 
of  typical  dislocations,  are  best  shown 
by  Kocher's  method  of  reducing  sub- 
coracoid  dislocations  of  the  shoulder, 
and  Middeldorpf's  method  of  reducing 
dorsal  dislocations  of  the  hip-joint.  The 
former  will  be  fully  described  in  the 
section  on  special  dislocations  of  these 
joints.  The  use  of  a  general  anesthetic 
is  usually  necessary  in  facilitating  manip- 
ulation, by  securing  the  benefits  accruing 
from  perfect  relaxation  of  the  muscles, 
as  well  as  to  render  the  procedure 
painless.  The  tise  of  pidleys  or  other 
mechanical  devices  of  great  power  is  seldom  made  at  the  present  time, 
as  their  employment  is  attended  by  risks  that  should  be  avoided, 
and  with  very  few  exceptions,  indeed,  they  can  be  dispensed  with  if 
the  physician  will  locate  accurately  the  position  of  the  displaced 
head  of  the  bone,  and  not  forget  that,  with  the  patient  fully  under  the 
influence  of  an  anesthetic,  the  only  serious  obstacle  to  the  reduc- 
tion is  the  untorn  portion  of  the  capsule,  and  that  when  this  is  not 
placed  on  the  stretch  by  the  manipulations,  the  head  of  the  bone 
can  be  rolled  into  place  Avith  very  little  force.  If  considerable  force 
becomes  necessary  in  the  reduction  of  rece7it  difficidt  cases  or  old  tinre- 
duced  dislocations,  the  traction,  manual  or  instrumental,  as  the  case 
may  be,  must  be  made  in  a  direction  that  will  not  expose  important 
vessels  and  nerves  to  harmfid  trauma.  Very  little  is  to  be  expected 
from  gradual  extension  by  weight  or  pulley  or  by  india-rubber  in 


Fig-  385. — Middeldorpf's 
(Bigelow's)  method  of  reduction 
of  a  dislocation  of  the  head  of 
the  femur  upon  the  dorsum  ilii 
by  manipulation. 


REDUCTION    BY    MANIPULATION. 


583 


Fig.  386. — Old  unreduced  iliac  dislocation  of  the  femur. 


Fig.  387. — Sul;luxali(jii  of  tlit  foot  liackward. 


584  DISLOCATIONS. 

the  treatment  of  otherwise  irreducible  dislocations,  both  old  and 
recent.  If,  after  faithful  attempts  at  reduction  by  the  bloodless 
method,  repeated,  if  need  be,  several  times  and  with  the  assistance 
of  at  least  one  consultant,  reduction  is  not  successful,  the  propriety 
of  resorting  to  the  open  method  must  seriously  be  considered. 
The  probable  benefits  to  be  derived  from  it,  as  well  as  the  imme- 
diate and  remote  risks  that  attend  it,  must  be  fully  explained  to  the 
patient  before  proceeding. 

Open  Method  of  Reduction. — If  the  ordinary  and  safe  methods 
of  reduction  fail,  and  the  patient's  general  condition  warrants  the 
performance  of  an  operation,  it  is  much  safer  and  the  result  more 
certain  to  resort  to  the  open  method  than  to  persist  in  making 
forcible  attempts,  with  the  dangers  incident  to  them  and  the  uncer- 
tainty of  accomplishing  the  desired  object.  Recent  irreducible  dis- 
locations are  usually  made  so  by  an  uncertain  or  erroneous  diag- 
nosis. No  number  of  manipulations  or  amount  of  traction  could 
succeed  in  reducing  the  dislocated  head  of  a  bone  separated  from 
the  adjoining  socket  by  the  interposition  of  soft  tissues,  a  fragment 
of  the  torn  capsule,  or  an  adjacent  muscle  or  tendon.  There  are 
cases,  too,  in  which  the  head  of  a  bone  escapes  through  a  slit  in  the 
capsule  not  large  enough  to  permit  its  return  by  bloodless  methods 
short  of  tearing  off  a  considerable  part  of,  if  not  the  entire,  capsule. 
A  similar  difficulty  would  be  encountered  if  the  head  of  the  bone, 
after  escaping  through  a  rent  in  the  capsule,  should  change  its  loca- 
tion, being  subsequently  displaced  from  one  side  of  the  joint  to  the 
other.  Under  such  and  similar  circumstances  open  reduction  under 
strict  aseptic  precautions  inflicts  less  damage  upon  the  soft  tissues 
than  would  the  employment  of  a  dangerous  amount  of  force.  The 
exposure  of  a  joint  by  an  open  incision  always  reveals  the  loca- 
tion and  nature  of  the  obstacle  that  resisted  reduction,  which,  when 
removed,  opens  the  way  for  the  return  of  the  dislocated  bone.  In 
irreducible  dislocations  the  open  method  enables  the  surgeon  to  make  a 
correct  diagnosis,  locate  and  remove  the  cause  of  interference  with  re- 
position, and  return  the  bone,  with  little  or  no  violence,  into  its  natural 
position. 

The  open  method  recommends  itself,  however,  more  especially 
in  the  treatment  of  old  dislocations  where  the  bloodless  method 
has  failed,  and  where,  owing  to  the  length  of  time  that  has  elapsed 
since  the  injury  has  occurred,  it  is  deemed  useless  to  give  it  a  trial. 
It  is  in  this  class  of  cases  that  accidents  of  a  serious  nature  have 
occurred  so  often  in  attempting  reduction  by  the  bloodless  method, 
and  that  the  procedure  has  so  often  failed.  By  exposing  the 
articular  end  of  the  bone,  ligaments,  and  socket  by  a  careful  dis- 
section, important  structures  are  protected  against  injury,  and 
by  direct  means  of  reduction  the  bone  can  be  replaced.  If  this 
latter  is  found  impossible,  pressure  symptoms  are  relieved  and 
mobility  of  the  limb  increased  by  resection  of  the  head  of  the 
bone.      The  operation  must  be  performed  under  the  most  pedantic 


OPEN    METHOD    OF    REDUCTION.  585 

aseptic  precautions,  as  wound  infection,  under  such  conditions, 
might  result  in  very  grave  compHcations,  and  in  the  event  of  intra- 
articular suppuration,  after  a  successful  reduction,  would  almost  be 
certain  to  impair,  if  not  complete!}^  suspend,  joint  motion. 

The  incision  is  made  with  special  reference  to  securing  free  ex- 
posure of  the  end  of  the  dislocated  bone  and  the  adjacent  socket, 
and,  with  another  important  object — the  protection  of  important 
structures  in  the  fielci  of  operation.  The  incisions  that  will  be  de- 
scribed and  recommended  in  the  chapter  on  Resections  will  be  found 
well  adapted  for  the  operation.  Good  retractors,  an  elevator, 
curved  scissors,  hemostatic  and  two  dissecting  forceps,  are  the  most 
important  instruments  in  the  direct  reposition  of  the  dislocation. 
Free  exposure  of  the  head  of  the  bone,  removal  of  interposed 
soft  tissues,  enlargement  of  the  capsular  rent,  retraction  of  resisting 
muscles  and  tendons,  are  the  most  important  preliminary  steps  to 
the  reduction.  In  old  dislocations  the  separation  of  adhesions  by 
dissection  or  the  use  of  blunt  instruments  is  always  necessary 
before  reduction  is  attempted.  After  the  head  of  the  bone  has  been 
freel}^  exposed  and  isolated,  and  the  way  to  the  socket  cleared  of  all 
obstacles,  the  reduction  is  usually  accomplished  without  much  diffi- 
culty by  rolling  the  head  into  its  proper  position.  A  certain 
amount  of  traction  may  be  necessary  before  this  can  be  done.  In 
old  cases  the  use  of  the  elevator  may  likewise  be  required.  After 
the  bone  has  been  placed  in  proper  position,  the  capsule  should  be 
sutured  with  catgut,  the  hemorrhage  carefully  arrested,  the  wound 
closed  throughout  in  the  usual  manner,  and  sealed  with  strips  of 
iodoform  gauze,  a  thin  film  of  aseptic  absorbent  cotton,  and  col- 
lodion, and  the  limb  immobilized  in  a  position  that  will  relieve  all 
tension  on  the  injured  side  of  the  capsule.  In  reducing  a  dislocation 
of  the  head  of  the  humerus  complicated  by  a  fracture  of  the  upper 
portion  of  the  shaft  of  the  bone,  McBurney  drills  the  fragment 
and  inserts  a  hook,  supplied  with  a  handle,  into  the  perforation, 
with  which  the  necessary  traction  and  rotation  are  made.  After 
the  reduction  of  an  old  dislocation,  whether  by  the  open  method  or 
b}'  manipulation,  immobilization  of  the  limb  must  be  continued  for 
a  longer  time  than  after  a  recent  case,  as  the  more  extensive  injury 
of  the  capsule  requires  a  longer  time  for  the  completion  of  the 
process  of  repair. 

Allusion  must  be  made  to  some  of  the  more  important  accidents 
that  have  occurred  during  efforts  at  reducing  dislocations.  One 
ofthc.se  is  tearing  of  the  skin  by  excessive  and  improperly  applied 
traction,  an  injury  that  will  not  occur  if  ordinary  care  is  exercised. 
Fracture  of  the  bone  has  occurred  in  the  practice  of  able  and  care- 
ful surgeons,  and  is  most  likely  to  take  place  when  the  bone  has 
become  exceptionally  fragile  from  j^rolonged  nonuse,  as  is  often  the 
case  in  old  unreduced  dislocations.  I  met  such  an  instance,  the 
case  being  one  of  subcoracoid  dislocation  of  the  humerus  of  long 
standing.      The   bone   fractured    through   the   surgical   neck.      The 


586 


DISLOCATIONS. 


injury  was  treated  in  the  same  manner  as  a  recent  fracture,  and  it 
was  a  source  of  comfort  to  learn  later  that  this  mishap  rather 
improved  the  condition  of  the  arm  than  otherwise.  The  risk  of  in- 
curring such  an  accident  is  an  additional  argument  in  favor  of  the 
open  method  of  reduction  in  all  cases  that  do  not  yield  to  a  safe 
degree  of  force  and  when  there  is  reason  to  suspect  that  the  bone 
is  exceptionally  fragile. 

One  of  the  accidents  that  is  most  feared  in  forcible  attempts  to 
reduce  a  dislocation' of  the  shoulder  is  rupture  of  the  axillary  artery. 
Stimson  has  collected  forty-seven  cases  of  rupture  of  this  vessel, 
caused  by  forcible  attempts  to  reduce  shoulder-joint  dislocations, 
and  of  this  number,  thirty-one  died.  I  have  personal  knowledge 
of  two  cases  that  occurred  in  the  practice  of  two  very  able  and  care- 
ful surgeons.  In  both  cases  the  axillary  artery  was  tied.  In  one, 
gangrene  of  the  whole  arm  supervened  and  an  amputation  at  the 
shoulder-joint  barely  saved  the  patient's  life  ;  in  the  other  case  the 
dislocation  remained  unreduced  and  the  patient  recovered  partial 
use  of  the  arm. 

Tearing  either  the  subscapular  or  the  circumflex  artery  during 
attempts  to  reduce  anterior  dislocations  of  the  shoulder  is  a  less 
serious  accident,  one  from  which  the  patients  usually  recover  with- 
out operative  interference.  In  this  accident  the  blood  supply  is 
not  threatened  to  the  same  extent  as  in  rupture  of  the  axillary 
artery.  Injury  of  the  principal  nerves  in  the  axillary  space  is  an- 
other accident  that  has  been  produced  by  violent  traction  and 
severe  pressure.  Violence  has  been  carried  to  the  extent  of  tear- 
ing out  the  roots  of  the  brachial  plexus.  Syncope  and  sudden 
death  have  occurred  during  attempts  to  reduce  dislocations,  more 
especially  old  ones,  of  the  shoulder-joint.  I  very  nearly  lost  two 
patients  on  the  table  during  prolonged  efforts  to  reduce  ancient  dis- 
locations of  the  shoulder-joint. 

The  foregoing  recital  of  the  immediate  complications  consequent 
upon  violent  or  misdirected  efforts  to  reduce  dislocations  by  the 
bloodless  method  should  be  a  sufficient  caution  to  the  practitioner 
to  use  every  possible  precaution  in  averting  such  evils  by  substitut- 
ing skill  for  excessive  force.  In  difficult  cases  he  should  resort, 
under  proper  aseptic  precautions,  to  the  open  method,  rather  than 
persist  in  the  use  of  violent  and  too  forcible  traction,  bending,  and 
rotation. 

DISLOCATIONS  OF  THE  SHOULDER- JOINT. 

Anatomically  and  functionally  the  shoulder-joint  is  more  predis- 
posed to  dislocations  than  any  other  joint  in  the  body,  thus  explain- 
ing why  dislocations  of  this  joint  equal  in  frequency  dislocations  of 
all  other  joints.  The  greater  exposure  of  men  to  all  kinds  of 
injury  than  women  accounts  for  the  greater  number  of  dislocations 
of  this  joint  among  males  than  females,  the  proportion  being  about 
four  to  one. 


MECHANISM  OF  TRAUMATISM.  587 

Age  is  an  important  predisposing  cause,  as  dislocations  of  this 
joint  are  rare  in  youth  and  old  age,  periods  of  life  when,  from  the 
same  force,  fractures  are  more  hable  to  occur  than  dislocations. 
Statistics  show  that  the  largest  number  occur  during  middle  age. 
The  left  humerus  is  more  frequently  dislocated  than  the  right.  The 
support  furnished  to  the  head  of  the  humerus  above  by  the  acro- 
mion process,  the  coracoid  process,  and  the  coraco-acromial  liga- 
ment excludes  a  typical  dislocation  in  that  direction.  A  disloca- 
tion upward  is  very  rare,  and  always  atypical,  as  it  is  necessarily 
complicated  by  fracture  of  the  bony  roof,  which  covers  the  head 
of  the  humerus  above  the  glenoid  cavity.  A  primary  dislocation 
of  the  head  of  the  humerus  downward  into  the  axillary  space  is  also 
a  rare  accident,  as  the  capsule  below  the  joint  is  enforced  and  greatly 
strengthened  by  the  long  head  of  the  triceps  muscle. 

The  weakest  points  of  the  shoulder-joint  are  in  front  and  behind, 
and  it  is  in  these  directions  that  dislocation 'usually  occurs,  so  that 
practically  all  dislocations  of  the  shoulder  areeither  anterior  or  pos- 
terior. The  following  will  give  an  idea  of  the  varieties  and  subva- 
rieties,  and  their  relative  frequency  : 

Anterior  I  Subcoracoid,   very  common  ;    intracoracoid,   exceptional ;   sub- 

\  clavicular,  very  rare. 

Downward      /Subglenoid,    uncommon;     erecta    (Middeldorpf),    very    rare; 
\  Subtricipital  (?). 

Posterior.  Subacromial,  rare  ;  subspinous,  very  rare. 

Upward.  Supraglenoid,  very  rare  and  always  atypical. 

Anterior  dislocations,  with  the  subvarieties,  subcoracoid,  intra- 
coracoid, and  subclavicular,  are  the  luxations  with  which  the  general 
practitioner  has  usually  to  deal,  and  of  these,  the  last  two  subvari- 
eties are  very  uncommon,  but  are  amenable  to  the  same  treatment 
as  the  subcoracoid.  The  main  interest,  therefore,  in  the  discussion 
of  dislocations  of  the  shoulder-joint  centers  in  the  displacement  of 
the  head  of  tiie  humerus  forward,  underneath  the  coracoid  process 
of  the  scapula. 

Mechanism  of  Traumatism. — Forward  or  preglenoid  dislo- 
cation of  the  shoulder  is  caused  by  direct  or  indirect  violence  or 
muscular  contraction.  In  the  great  majority  of  cases  it  is  produced 
by  indirect  force,  transmitted  through  the  shaft  of  the  humerus — 
usually  by  a  fall  upon  the  outstretched  hand  or  elbow.  The  arm  is 
brought  into  a  hyperabducted  position,  and  the  head  of  the  humerus 
is  forced  against  tlie  inner  and  hnver  portion  of  the  capsule,  while 
the  highest  [joint  of  the  greater  tuberosity  rests  against  the  upper 
margin  of  the  glenoid  cavity,  and  tlie  surgical  neck  of  the  humerus 
against  the  acromion  process.  If,  with  the  arm  in  this  position,  the 
force  continues,  tlie  humerus  becomes  the  lever,  the  margin  of  the 
glenoid  cavity  and  the  acromion  the  fulcnun,  the  head  of  the 
humerus  under  lever  action  tearing  through  the  anterior  and  inferior 
portion  of  the  capsule,  and  escaping  into  the  axilla.     The  position  of 


588 


DISLOCATIONS. 


the  arm  and  the  head  of  the  humerus  will  now  depend  on  the  action 
of  displacing  forces  after  the  head  of  the  bone  has  escaped  through 
the  rent  in  the  capsule.  If  the  arm  at  this  moment  is  held  in  the  ver- 
tical position  by  the  untorn  portion  of  the  capsule,  drawn,  perhaps, 
a  little  closer  toward  the  chest  by  the  latissimus  dorsi  and  pecto- 
ralis  major  muscles,  the  head  of  the  humerus  is  opposite  the  infra- 
glenoid    tubercle,   with   the    articular  surface   directed    downward. 


Fig.  388. — Position  of  arm  in  luxatio 
humeri  erecta  (Hoffa). 


Fig.   389. — Retroglenoid  or   posterior 
dislocation  of  the  humerus  (Hoffa). 


Fig.  390.— Position  of  arm  in  subclavicular  dislocation  of  the  humerus  (Hoffa). 

Such  dislocation  has  been  described  by  Middeldorpf  as  erecta,  a 
very  rare  subvariety  of  anterior  dislocation.  If  the  head  of  the 
humerus  during  the  secondary  movement  remains  below  the  glen- 
oid cavity,  or  if  it  moves  only  slightly  along  its  inner  border, 
a  downward  or  infraglenoid  dislocation  has  taken  place.  If| 
on  the  other  hand,  the  head  ascends  higher  in  front  of  the 
glenoid  cavity,  so   that    it   reaches   the    space  below  the  coracoid 


PATHOLOGIC    ANATOMY. 


589 


process,  between  the  thorax  and  the  anterior  border  of  the  glenoid 
cavity,  as  is  usually  the  case,  there  results  by  far  the  most 
common  form  of  dislocation — the  subcoracoid  subvariety  of  the 
anterior  dislocations.  If  the  head  of  the  bone  finds  its  way  to  the 
inner  side  of  the  coracoid  process  without  touching  any  other  part 
of  the  scapula,  and  ascends  to  near  the  clavicle,  the  injury  is 
designated  a  subclavicular  dislocation.  The  dislocation  is  called 
intracoracoid  if  the  head  of  the  humerus  is  displaced  in  the  same 
direction,  when  a  small  portion  of  the  articular  surface  remains  in 
contact  with  the  coracoid  process.  Both  of  these  latter  subvarieties 
are  exceedingly  rare,  and,  as  has  been  stated  before,  are  amenable 
to  the  same  methods  of  reduction  as  the  subvariety,  subcoracoid. 

Dislocation  of  a  normal 
joint  from  muscular  contrac- 
tion is  very  rare,  but  happens 
occasionally  by  throwing 
movements  of  the  arm,  as  in 
throwing  stones,  balls,  etc. 
The  displacing  force  is  created 
in  such  cases  by  the  antagon- 
ism between  the  deltoid  mus- 
cle, which  elevates  the  arm,  on 
the  one  hand,  and  the  great 
pectoral  and  latissimus  dorsi, 
which  draw  the  arm  down- 
ward, establishing  a  pendu- 
lum action  of  the  arm  between 
the  points  of  attachment  of 
these  muscles,  on  the  other. 
Under  forcible  abduction  the 
luxation  takes  place  in  the 
same  manner  as  by  indirect 
force  transmitted  through  the 
shaft  of  the  humerus.  A  blow 
or  fall  upon  the  shoulder  may 

dislocate  the  head  of  the  humerus  forward  if  the  force  strikes  the 
greater  tuberosity,  forcing  the  head  of  the  bone  through  the  weak- 
est portion  of  the  capsule  in  its  anterior  lower  segment.  The  cases 
in  which  the  capsule  of  the  joint  is  not  torn  by  the  dislocating  force 
are  exceptional.  The  dislocation  may  be  partial,  but  such  ca.ses 
are  very  rare. 

In  subcoracoid  anterior  dislocations  of  the  shoulder  the  dis- 
located head  of  the  humerus  is  beneath  and  in  contact  with  the 
coracoirl  {process. 

Pathologic  Anatomy. — In  subcoracoid,  by  far  the  most  frequent 
dislocation  of  the  humerus,  the  capsule  is  found  ruptured  on  the 
anterior  and  inferior  segment  of  the  circumference  of  the  joint, 
between  the  tendon  of  the  subscapularis  muscle  and  the  long  head 


Fig.  391- 
retroglenoid 
(Hoffa). 


—Deformity  of  the  shoulder  in 
dislocation     of     the     humerus 


590 


DISLOCATIONS, 


of  the  triceps.  The  extent  of  the  rupture  varies  :  it  may  be  so  large 
as  to  permit  free  to-and-fro  motion  of  the  head,  or  the  margins  of 
the  sHt  may  hug  the  neck  of  the  bone  so  closely  that  reduction 
is  impossible  without  direct  operative  interference.  The  untorn 
portion  of  the  capsular  ligament  remains  on  the  stretch  so  long  as 
the  bone  is  in  its  abnormal  position,  and  is  the  principal  factor  in 
the  immobilization  of  the  dislocated- bone.  The  tension  is  most 
marked  in  the  fibers  that  lie  on  each  side  of  the  passage  of  the  sub- 
scapularis  in  the  capsule,  and  from  the  margin  of  the  glenoid  cavity 
to  the  small  tuberosity  and  neck  of  the  humerus,  and  especially  the 

coracohumeral  ligament. 
The  untorn  portion  of  the 
subscapular  muscle  maybe 
interposed,  and  the  capsu- 
lar portion  of  the  supra- 
spinatus,  infraspinatus,  and 
teres  minor  may  be  torn  ; 
the  long  head  of  the  biceps 
is  occasionally  ruptured. 
A  portion  of  the  greater 
tuberosity  may  be  found 
detached.  The  primary 
swelling,  outside  of  that 
made  up  by  the  head  of 
the  dislocated  bone,  con- 
sists of  extravasated  blood, 
varying  greatly  in  amount 
according  to  the  extent  of 
injury  to  the  soft  parts  and 
the  number  and  size  of  rup- 
tured vessels.  The  muscles 
placed  most  on  the  stretch 
are  the  deltoid,  coracobra- 
chialis,  and  the  short  head 
of  the  biceps.  The  long 
head  of  the  biceps,  with 
that  of  the  triceps,  makes 
up  a  sling  around  the  neck 
of  the  humerus.  Limited  traction  fractures  involving  the  bony 
prominences  around  the  head  of  the  bone  are  not  infrequently 
found.      Fracture  of  the  surgical  neck  is  a  rare  complication. 

The  larger  vessels  and  nerve-trunks  are  always  stretched  by  the 
head  at  the  moment  hyperabduction  reaches  the  maximum  limit, 
but  later  they  escape  harmful  pressure  by  the  head  gliding  later- 
ally toward  the  inner  side.  With  the  exception  of  the  subscapu- 
lar artery,  tearing  of  vessels  of  considerable  size  is  very  rare. 
Cyanosis  of  the  limb  is  not  an  unusual  occurrence,  and  is  caused 
by  compression  of  the  large  veins.      The  nerve  injuries  resulting 


Fig.  392. 


-Subcoracoid  dislocation  of  tbe 
humerus  (Hoffa). 


SYMPTOMS. 


591 


from  the  dislocation  seldom  give  rise  to  permanent  paralysis,  with 
the  exception  of  paralysis  of  the  deltoid  muscle  caused  by  tearing 
of  the  circumflex  nerve,  which  usually  passes  directly  over  the  most 
prominent  part  of  the  dislocated  head,  and  consequently  is  some- 
times severed  or  permanently  damaged  by  overstretching. 

Symptoms. — It  has  been  said  that  a  subcoracoid  dislocation 
can  be  recognized  through  the  patient's  clothing.  While  this  may 
be  true  in  some  cases  so  far  as  the  existence  of  this  injury  is  con- 
cerned, no  careful  physician  would  be  willing  to  base  his  prog- 
nosis and  treatment  on  so  superficial  and  often  deceptive  a  diag- 
nostic ground.  It  is  necessary  not  only  to  recognize  the  disloca- 
tion, but  also  to  ascertain  the  presence  of  complications  if  they 
exist.      A  subcoracoid  dislocation  must  be  suspected  if  the  patient, 


I-'ig.  393.  —  halj(_uracoid  dislocation  of 
the  humerus,  showing  deviation  from  the 
jiormal  axis  of  the  humerus  (Clinic,  Rush 
Medical  College). 


Fig.  394. — Subcoracoid  dislocation  of 
the  humerus,  exhibiting  depression  below 
the  acromion  process  (Clinic,  Rush  Medical 
College). 


in  a  standing  or  sitting  position,  inclines  his  head  and  trunk  toward 
the  injured  side,  and  if  he  holds,  with  the  healthy  hand,  the  forearm 
with  the  arm  in  an  abducted  position.  The  elbow  is  always  a  little 
way  from  tiie  side  (jf  the  chest,  and  never  touches  the  chest.  The 
])aticnt  invariably  complains  of  severe  pain  in  the  shoulder,  and  if 
the  axillary  plexus  has  jjcen  severely  stretched  or  is  compressed, 
of  pain  in  the  whole  arm,  numbness,  and  creeping  sen.sations  in  the 
forearm  and  fingers. 

In  conducting  the  examination,  the  clothing  must  be  removed  as 
far  as  the  waist,  for  the  purpose  of  making  the  necessary  conii^ari- 
son,  by  inspection,  palpation,  and  measurements,  between  the  im- 
paired and  the  healthy  side.  Inspection  will  reveal,  at  once,  besides 
the  characteri.stic  abduction  and  absolute  helplessness  of  the  arm,  a 


592  DISLOCATIONS, 

marked  change  of  contour  of  the  shoulder-joint.  The  acromion 
process  is  preternaturaUy  prominent,  and  below  it  the  rotundity 
of  the  shoulder  has  disappeared,  a  deep  depression  being  seen  in- 
stead. This  subacromial  flatness  or  depression  is  caused  by  the  dis- 
appearance of  the  upper  end  of  the  humerus,  which  then  presents 
itself  in  front  of  the  glenoid  cavity  and  below  the  coracoid  process, 
in  Mohrenheim's  fossa,  in  the  form  of  a  firm,  globular  swelling,  to 
which  the  movements  of  the  humerus  are  imparted.  The  deltoid 
is  apparently  elongated,  flattened,  and  its  anterior  border  prominent. 
As  the  upper  end  of  the  humerus  is  displaced  inward,  the  points  of 
origin  and  insertion  of  the  pecto rails  major  and  latissimus  dorsi  are 
approximated,  a  condition  that  accounts  for  a  folding  of  the  skin 
at  the  lower  margin  of  the  anterior  and  posterior  wall  of  the  axillary 
space.  The  position  of  the  arm  is  almost  characteristic.  The 
elbow  is  distant  from  the  chest-wall  from  one  to  two  inches,  and  is 
at  the  same  time  directed  somewhat  backward.  The  arm  is  almost 
fixed  in  its  faulty  position.  It  is  impossible,  on  placing  the  hand 
over  the  opposite  shoulder,  to  bring  the  elbow  in  touch  with  the  side 
of  the  chest  (test  of  Dugas).  This  test,  if  not  infallible,  is,  at  least, 
of  great  diagnostic  value  in  differentiating  a  fracture  in  or  near  the 
joint  from  a  dislocation.  In  palpating  the  region  below  the  acro- 
mion no  bony  resistance  can  be  felt. 

If,  in  the  case  of  a  very  obese  patient,  or  in  the  presence  of  a 
large  swelling,  there  is  any  doubt  as  to  the  absence  of  the  head  of  the 
humerus,  on  making  axillary  palpation  this  doubt  could  be  cleared 
up  by  exploration  through  the  deltoid,  half  an  inch  below  the  acro- 
mion, with  an  aseptic  steel  needle  (akidopeirasty  of  Middeldorpf ), 
If  the  physician  has  recognized  and  established  the  presence  of  a 
faulty  axis  of  the  shaft  of  the  humerus,  pointing  toward  the  coracoid 
process  instead  of  the  glenoid  cavity,  he  has  demonstrated  the 
existence  of  either  a  subcoracoid  dislocation  of  the  head  of  the 
humerus  or  a  fracture  through  one  of  the  necks  of  the  bone. 
Owing  to  the  rarity  of  the  latter  accident  as  compared  with  the 
former,  the  probability  is  strongly  in  favor  of  a  dislocation.  If  the 
head  of  the  humerus  can  be  felt  in  Mohrenheim's  fossa  instead  of  in 
the  glenoid  cavity,  the  diagnosis  of  dislocation  becomes  unmistaka- 
ble. If  the  arm  is  more  movable  than  usual  and  the  springy 
condition,  so  constantly  present  in  the  typical  form  of  dislocation, 
be  absent,  we  may  suspect  avulsion  of  the  margin  of  the  glenoid 
cavity  or  the  tuberosities  of  the  humerus.  The  limb  is  always 
shortened  in  subcoracoid  luxation.  Having  made  a  diagnosis  of 
dislocation,  the  physician  makes  careful  search  for  complications. 

The  complications  that  are  most  important  to  remember  are 
fracture,  rupture  of  blood-vessels  of  considerable  size,  and  contusion 
or  laceration  of  the  principal  nerve-trunks.  The  condition  of  the 
circulation  of  the  limb  below  the  seat  of  injury  is  inquired  into, 
as  well  as  any  disturbances  of  innervation  in  the  distribution  of  the 
principal  nerve -trunks.     The  most  prominent  symptoms    of  sub- 


SYMPTOMS. 


593 


Fig.  395. — Recent  fracture  of  the  surgical  neck  of  the  humerus. 


Tig.  396. — Fracture  of  the  surgical  neck  of  the  humerus  two  years  and  a  half 
after  the  accident. 

38 


594 


DISLOCATIONS. 


clavicular  and  intracoracoid  dislocations,  as  compared  with  subcora- 
coid,  are  further  displacement  upward  of  the  head  of  the  humerus, 
the  more  widely  abducted  elbow,  and  more  flattening  or  depression 
below  the  acromion.  Pathologically  we  find  in  such  cases  more 
extensive  laceration  of  the  capsule  and  more  tearing  of  the  subscap- 
ulars muscle. 

In  the  erect  form  of  anterior  dislocation  Middeldorpf  mentions, 
as  the  most  important  diagnostic  symptoms,  vertical  position  of  the 
arm,  elbow  on  a  level  with  the  head,  and  arm  flexed  in  such  Avay 
that  the  dorsal  surface  of  the  hand  rests  on  the  top  of  the  head 
(Fig.  388). 

Treatment. — A  positive  diagnosis  of  a  dislocation  having  been 


Fig-  397-— Avicenna's  method  of  reduction  of  subcoracoid  dislocation  (Hoffa). 

made,  in  the  absence  of  specific  contraindications  no  time  should  be 
lost  in  attempts  to  replace  the  bone  in  its  usual  position.  The 
earlier  the  reduction  is  made,  the  sooner  the  patient  will  be  relieved 
of  pain,  and  the  less  will  be  the  resistance  to  reduction  and  the  better 
the  prospects  of  a  good  functional  result.  Many  of  the  old  methods 
of  reduction  of  the  shoulder-joint  are  no  longer  in  use,  as  they  are 
not  in  accord  with  the  pathologic  anatomy  of  the  injury  as  devel- 
oped during  the  last  half  century.  Force  was  the  most  important 
feature  of  the  old  methods,  while  due  regard  for  the  resisting  struc- 
tures and  gentleness  characterize  the  modern. 

Forcible  traction  in  the  axis  of  the  body,  with  the  heel  in  the 


TREATMENT.  595 

axilla,  a  method  of  reduction  usually  attributed  to  Sir  Astley  Cooper, 
Avas  known  to  Ambroise  Pare,  in  whose  work  on  surgery  a  very 
creditable  illustration  of  this  procedure  can  be  found. 

Position  with  manual  pressure,  a  method  devised  and  described 
by  Avicenna,  is  safe  and  frequently  succeeds  in  the  reduction  of 
subcoracoid  and  other  dislocations  of  the  humerus.  It  is  well 
shown  in  figure  397. 

Extension  in  the  direction  of  the  dislocated  member,  combined 
with  counterextension  by  a  hand  over  an  axillar}'  cushion  and 
another  over  the  acromion  process,  is  an  old  method,  and  one 
which,  when  employed  with  proper  care,  is  devoid  of  any  great 
risks.      It  will  occasionally  succeed  after  manipulation  has  failed. 

Extension  of  the  limb  in  a  vertical  position,  first  recommended 
by  Mothe,  is  attended  by  more  risk,  and  if  used  at  all,  combined 


Fig.  398. — Reduction  by  extension  in  the  axis  of  tlie  dislocated  humerus  (Hoffa). 

with  pressure  over  the  shoulder  and  in  the  axilla,  must  be  made 
with  the  utmost  care,  to  guard  against  injury  of  any  of  the  important 
axillary  contents. 

The  lever  method,  by  using  the  humerus  as  a  lev^er  and  the 
knee  or  closed  fist  as  a  fulcrum,  may  be  tried  with  safety,  and  will 
occasionally  succeed  after  other  methods  have  failed. 

The  rotation  method,  based  entirely  on  the  principle  of  avoid- 
ing, during  manipulation,  the  mechanical  resistance  offered  by  mus- 
cles and  the  untorn  portion  of  the  capsule,  is  the  method  above  all 
others,  as  it  precludes  all  accidents,  and  with  few  exceptions,  indeed, 
if  properly  i)erformed,  proves  successful.  In  many  cases  the  rota- 
tion method  enables  the  physician  to  reduce  the  dislocation  easily, 
even  without  the  use  of  an  anesthetic.      The  rotati(jn  methods  have 


596 


DISLOCATIONS. 


been  devised  and  practised  only  recently.     Schinzinger  gives  the 
following  directions  : 

The  patient  sits  on  a  chair.  The  scapula  is  fixed  by  an  assistant 
placing  his  hands  over  the  shoulder,  making  pressure,  and  at  the 
same  time  grasping  the  bone.  The  physician  sits  on  a  chair  oppo- 
site the  patient,  grasps,  with  both  hands,  the  forearm,  flexed  at  a 
right  angle,  presses  the  arm  against  the  chest,  and  then  makes  out- 
ward rotation  until  the  hand  is  directed  outward,  or  even  a  little 
beyond  this  point,  from  the  adducted  arm.  At  this  moment  the 
greater  tuberosity  of  the  humerus  presses  against  the    posterior 


Fig.  399. — Correction  of  abduction. 


Fig.  400. — Abduction  and  external  rotation. 


border  of  the  glenoid  cavity.  When  this  resistance  is  felt,  the  arm 
is  raised  somewhat,  when  rapid  inward  rotation  is  made,  which  rolls 
the  head  into  the  socket.  In  intracoracoid  dislocations  Kocher 
recommends  adduction  of  the  arm  and  outward  rotation  ;  then 
the  arm  is  carried  in  a  vertical  plane,  and  finally  rotated  inward 
and,  at  the  same  time,  carried  to  the  side  of  the  chest. 

In  subcoracoid  dislocation  Kocher's  rotation  method  yields  the 
best  results,  and  is  the  one  now  generally  accepted  and  practised. 
The  reduction  is  made  by  rotation  in  the  abduction  position  of  the 
bone.  He  recommends  that,  after  correction  of  the  abduction,  the 
arm  first  be  abducted,  to  relax  the  coracohumeral  ligament,  when 


POSTERIOR    OR    RETROGLENOID    DISLOCATION. 


597 


outward  rotation  is  made,  followed  by  rapid  adduction  and  flexion. 
The  arm  is  then  not  only  brought  to  the  side,  but  also  over  the  an- 
terior surface  of  the  chest.  During  this  movement  the  arm  is 
rotated  inward  at  the  same  time.  During  the  abduction  and  out- 
ward rotation  of  the  arm  the  head  of  the  bone  rolls  outward,  in 
front  of  and  below  the  acromion,  and  during  the  adduction  and  in- 
ward rotation  it  glides  into  position.  During  any  of  the  methods 
mentioned  manipulations  by  an  assistant  with  his  hand  in  the  axilla 
are  often  of  signal  service. 

Downward  or  subglenoid  dislocation  has  ahead)-  been  re- 
ferred to  as  one  of  the  subvarieties  of  anterior  dislocation.  It  is 
always  produced  by  forcible  abduction  of  the  arm,  and  the  rent  in 
the  capsule  takes  place  in  front  of  and  below  the  circumference  of  the 
joint ;  the  head  remains  in  a  fixed  position  below  the  glenoid  cavity 
in  the  axilla.  The  lower  part  of  the  subscapularis  may  be  torn, 
and  the  greater 
tuberosity  is  usu- 
ally broken  off. 

The  symp- 
toms are  very 
similar  to  those 
of  subcoracoid 
dislocation,  but 
more  marked. 
The  elbow  is 
further  from  the 
chest,  and  the 
flattening  below 
the  acromion 
more  conspicu- 
ous. The  head 
of  the  humerus  can  be  felt  very  plainly  in  the  axilla.  Reduction  is 
usually  readily  effected  by  Kocher's  rotation  method,  and  if  this 
should  fail,  traction  in  the  direction  of  the  dislocated  member  and 
direct  pressure  should  be  tried. 

Posterior  or  retroglenoid  dislocation  is  of  very  rare  occur- 
rence, and  the  subvariety,  subacromial,  is  most  frcc|ucnt.  It  is 
caused  by  pressure  of  the  head  of  the  humerus  outward  and  back- 
ward, which  results  in  a  rupture  of  the  capsule  on  its  outer  side, 
and  above  and  below,  between  the  acromion  process  and  the  long 
head  of  the  triceps.  If  the  head  of  the  bone  is  displaced  backward 
beyond  the  acromion  into  the  infraspinatus  fossa,  that  ver\'  rare  form 
of  dislocation  is  produced  knowu  as  infraspinous  or  luxatio  infra- 
spinata.  Posterior  dislocation  is  very  seldom  produced  by  a  fall 
upon  the  out.strctchcd  hand  or  elbow  ;  it  is  much  more  frequently 
caused  by  direct  violence  apjjlied  over  the  anterior  surface  of  the 
head  of  the  bone,  driving  tlie  same  backward  through  the  rupture 
in  the  posterior  portion  of  the  capsule,  either  underneath  the  aero- 


Fig.  401. — Adduction,  flexion,  and  internal  rotation. 


598 


DISLOCATIONS. 


mion  or  into  the  infraspinous  fossa.  It  is  also  produced  by  muscle 
action. 

The  arm  hangs  at  the  side  of  the  chest  in  inward  rotation,  with 
elbow  directed  forward.  The  whole  shoulder  appears  markedly 
broadened  (Fig.  391).  The  coracoid  process,  the  anterior  margin 
of  the  acromion,  and  the  coraco-acromial  ligament  are  unusually 
prominent.  Below  the  acromion,  over  the  region  of  the  deltoid,  is 
a  deep  depression,  in  the  bottom  of  which  the  glenoid  cavity  can  be 
distinctly  felt.  Immediately  below  the  acromion,  or  in  the  intra- 
spinous  fossa,  the  displaced  head  of  the  humerus  presents  itself  in 
the  form  of  a  hard,  smooth,  globular  swelling,  which  follows  the 
movements  of  the  arm  and  becomes  more  prominent  during  each 
anteversion.  The  axis  of  the  humerus  falls  with  its  upper  end  out- 
ward and  behind  the  glenoid  cavity.  The  arm  itself  is  only  slightly 
abducted,  in  old  cases  abducted,  rotated  inward,  and  somewhat 
anteverted.  In  this  position  the  arm  is  fixed,  and  any  attempt  at 
passive  motion  is  productive  of  great  pain.  The  length  of  the  limb 
remains  normal,  or  slight  shortening  or  elongation  may  be  present. 
Supination  of  the  forearm  is  difficult  and  causes  pain. 

Reposition  of  posterior  dislocations  is  easy.  It  is  made  by 
elevating  the  arm  to  a  horizontal  level,  making  shght  extension, 
outward  rotation,  followed  by  rapid  adduction,  combined  with  pres- 
sure against  the  head  of  the  humerus  from  behind  forward.  Redis- 
location  in  such  cases  is  very  liable  to  occur,  owing  to  the  extensive 
injury  of  the  subscapular  muscle,  which  always  complicates  back- 
ward dislocations.  Unreduced  backward  dislocation  greatly  and 
permanently  impairs  the  usefulness  of  the  arm,  much  more  so  than 
do  dislocations  in  the  opposite  direction. 

In  dislocations  of  the  shoulder  complicated  by  fracture  near  the 
head  of  the  humerus  reduction  can  usually  be  made  by  the  plan 
devised  by  McBurney.  Through  a  puncture  a  perforation  is  made 
in  the  upper  fragment,  deep  enough  to  insert  a  strong  blunt  hook 
with  a  handle  attachment.  With  this  simple  instrument  the  neces- 
sary extension  and  other  manipulations  can  be  made  to  effect  reduc- 
tion, aided  by  pressure  against  the  bone  in  the  direction  of  the  glen- 
oid cavity.  After  the  reduction  of  the  upper  fragment,  the  usual 
treatment  for  fractures  in  that  locality  is  instituted  and  continued 
until  the  fracture  has  united  by  bony  callus. 

Space  will  not  permit  the  discussion  of  all  special  dislocations 
separately  and  in  detail.  I  have  attempted  to  treat  the  whole  sub- 
ject of  dislocations  somewhat  comprehensively,  and  have  described, 
at  length,  the  different  forms  of  shoulder-joint  dislocations,  with  the 
various  methods  of  their  reduction,  for  the  purpose  of  illustrating 
the  mechanism  of  production  and  reduction  of  ball-and-socket  joint 
dislocations.  The  descriptions  given  and  the  teachings  laid  down 
are,  to  a  large  extent,  applicable  to  dislocations  of  the  largest 
enarthrodial  joint — the  hip-joint.  The  important  role  played  by 
the  unruptured  portion  of  the  capsular  ligament  in  resisting  reduc- 


DISLOCATIONS    OF    THE    ELBOW -JOINT,  ^gg 

tion,  and  the  great  necessity  of  relaxing  it  in  attempting  reduction, 
are  perhaps  even  more  forcibly  shown  here  than  in  the  shoulder- 
joint.  The  manipulations  in  reducing  the  different  dislocations  of 
the  hip-joint  are  based  on  the  same  great  principles  used  in  relaxing 
the  untorn  portion  of  the  capsular  ligament  and  in  replacing  the 
head  of  the  humerus  by  rotation.  If  the  physician  has  ascertained  the 
exact  location  of  the  head  of  the  femur  and  that  of  the  rupture  in  the 
capsule  through  which  it  escaped,  he  will  have  but  little  difficulty  in 
planning  and  executing  the  movements  necessary  to  overcome  the 
resistance  of  the  untorn  portion  of  the  capsule  and  in  replacing  the 
bone  into  the  adjoining  socket  by  rotation. 

Hip-joint  dislocations  are  rare  as  compared  with  dislocations  of 
the  elbow-joint ;  hence  it  has  occurred  to  me  that  it  would  be  more 
profitable  for  the  reader  to  find  a  somewhat  detailed  account  of  dis- 
locations of  the  latter  joint,  instead  of  of  the  hip-joint.  I  have  seen 
so  many  cases  of  fracture  of  the  neck  of  the  femur  mistaken  for 
dislocation  that  I  feel  called  upon  to  emphasize  once  more  the 
importance  of  making  a  thorough  examination  in  all  cases  of  hip- 
joint  injuries,  to  guard  against  committing  so  serious  a  mistake. 
Fractures  of  the  neck  of  the  fejiinr  are  very  covunon  as  compared 
zvith  dislocations  ;  the  deformity  is  less  and  the  patients  are  usually 
persons  advanced  in  years,  and  the  violence  that  produced  the  injury  is 
insufficient  to  produce  a  dislocation.  Fracture  of  the  neck  of  the 
femur  is  generally  the  result  of  a  fall  upon  the  greater  trochanter ; 
dislocations  are  produced  by  forces  that  deviate  the  axis  of  the  femur 
sufficiently  to  tear  the  capsule  at  a  point  zvhere  the  head  of  the  bone^ 
in  consequetice  of  such  deviation,  makes  the  greatest  pressure. 

DISLOCATIONS  OF  THE  ELBOW-JOINT. 

Next  to  the  shoulder-joint,  the  elbow-joint  is  most  frequently 
the  seat  of  dislocation.  The  complicated  structure  of  this  joint,  its 
great  functional  activity,  and  its  repeated  exposure  to  all  sorts  of 
injuries  furnish  an  adequate  explanation  for  this  frequency. 

Dislocations  of  the  elbow-joint  are  more  common  in  children 
and  young  adults  than  in  persons  advanced  in  years.  The  elbow- 
joint  is  a  typical  ginglymoid,  or  hinge,  joint  of  great  strength,  and 
dislocations  occur  only  on  the  application  of  great  force.  The 
strength  of  the  joint  is  increased  by  the  many  bony  prominences 
that  enter  into  its  formation,  and  that  arc  but  imperfectly  developed 
in  children  and  young  adults.  About  1 8  per  cent,  of  all  disloca- 
tions involve  the  elbow-joint.  Both  bones  of  the  forearm  may  be 
dislocated  m  all  four  directions,  or  either  may  be  dislocated  alone. 

Dislocations  of  the  clbow-joint  are  more  frequently  complicated 
by  fractures  than  dislocations  of  any  other  joint.  .Some  of  the  dis- 
locations can  not  occur  without  fracture,  and  if  such  dislocations 
are  recognized,  it  is  safe  to  a.ssume  the  existence  of  a  fracture. 
The  extent  of  the  injury  to  the  soft  structures  and  the  frequency 


600  DISLOCATIONS. 

with  which  the  dislocations  are  compHcated  by  fracture,  have  an 
important  bearing  on  the  prognosis.  The  diagnosis  is  often  obscure, 
and  the  treatment  unsatisfactory.  The  X-ray  will  prove  of  the 
utmost  utility  in  making  the  diagnosis  positive  in  obscure  cases,  and 
the  additional  diagnostic  information  gained  by  the  employment  of 
this  diagnostic  resource  will  dispense  with  the  uncertainty  and  hesi- 
tation that  so  often  overshadow  such  cases  like  a  dark  cloud. 
Moreover,  the  information  gained  by  the  Rontgen  rays  will  enable 
us  to  devise  and  carry  into  effect  more  efficient  treatment  and  to 
obtain  more  satisfactory  results. 

CLASSIFICATION  OF  DISLOCATIONS  OF  THE  ELBOW. 

A.  Dislocations  of  both  bones  of  the  forearm  : 

-p    i  1      f  «,  without, 

'    \  b,  with,  fracture  of  the  coronoid  process. 

T-.  J         i  a,  without, 

2.      i:"orward,      <    ,       -^i     r^  r     i 

'       1^  b,  with,  iracture  oi  olecranon  process. 

1       T  qteral  /  ""'  outward. 

•^  ^  \  b,  inward. 

4.     In  different  directions.      Diverging  dislocations. 

B.  Dislocations  of  one  of  the  bones  of  the  forearm  : 

I.      Dislocation  of  the  ulna  backward. 

(a,  forward. 
b,  backward. 
c,  outward. 

A.  Dislocation  of  Both  Bones  of  the  Forearm. — Of  all  dis- 
locations of  the  elbow-joint,  displacement  of  both  bones  of  the  fore- 
arm backward  is  the  most  common. 

The  dislocation  may  be  partial  or  complete.  In  a  complete 
dislocation  the  lower  articular  end  of  the  humerus  is  in  front  of 
the  coronoid  process  of  the  ulna  and  the  neck  of  the  radius. 
Instead  of  the  olecranon,  the  coronoid  process  occupies  the  olecra- 
non fossa.  In  the  incomplete  form  the  coronoid  process  rests 
against  the  trochlear  surface,  and  the  head  of  the  radius,  with  its 
margin,  lies  under  the  eminentia  capitata. 

Causes. — The  usual  cause  of  a  backward  dislocation  of  both 
bones  of  the  forearm  is  a  fall  upon  the  outstretched  hand,  with  the 
elbow  in  hyperextension  or  the  forearm  abducted.  The  dislocation 
is  produced  by  lever  action  by  hyperextension.  When  the  hyper- 
extension is  carried  to  a  point  so  that  the  tip  of  the  olecranon  im- 
pinges upon  the  posterior  supratrochlear  fossa,  a  fulcrum  is  formed 
upon  which  the  articular  end  of  the  humerus  is  Hfted  forward.  The 
force  continuing,  the  anterior  portion  of  the  capsule  is  torn  and  the 
end  of  the  bone  escapes  through  the  rent,  while  both  bones  of  the 
forearm  are  drawn  upward  behind  it  by  the  action  of  the  triceps  and 
brachialis  anticus  muscles.  This  is  the  usual  mechanism  of  the 
production  of  a  posterior  dislocation  of  both  bones  of  the  forearm, 
although  Malgaigne  and  Stetter  are  of  the  opinion  that  dislocation 


SYMPTOMS. 


60 1 


in  the  same  direction  sometimes  takes  place  with  the  forearm  hyper- 
flexed,  the  dislocating  force  being  transmitted  from  the  hand  through 
the  bones  to  the  capsule.  Schiiller  has  shown  by  his  experiments 
that  the  same  displacement  can  be  produced  by  forcible  abduction 
or  adduction  of  the  forearm. 

In  a  posterior  dislocation  the  anterior  portion  of  the  capsule  and 
the  internal  and  external  lateral  ligaments  are  torn.  As  a  rule,  the 
laceration  in  the  internal  lateral  ligament  is  more  extensive  than  in 
the  external.  Both  epicondyles  may  be  detached,  the  internal  more 
frequently  than  the  external.  Not  infrequently  a  fracture  of  the 
coronoid  process  complicates  the  injury.  In  children  the  line  of 
fracture  is  usually  at  its  base  ; 
in  the  adult  more  frequently 
only  the  tip  is  detached.  Supra- 
condyloid  fracture  has  also  been 
seen  as  a  complication  of  this 
dislocation.  Without  exception, 
the  brachialis  anticus  is  found 
more  or  less  torn.  The  vessels 
in  the  bend  of  the  elbow  are  oc- 
casionally severely  injured,  and 
in  a  few  cases  the  traction  has 
been  so  severe  as  to  sever  the 
musculospiral  nerve. 

Symptoms. — The  most  con- 
spicuous symptoms  of  posterior 
dislocation  of  the  elbow  are 
partial  flexion  of  the  forearm 
and  absolute  immobility.  The 
di.splacements  can  be  distin- 
guished ver}^  readily  in  recent 
ca.ses,  but  during  the  following 
days  the  hemarthrosis  and  reac- 
tive infiltration  produce  a  swell- 
ing that  often  obscures  the  im- 
portant landmarks.  It  is  in 
such  instances  that  the  removal 

of  the  swelling  by  mas.sage  and  the  u.se  of  a  general  anesthetic 
renders  material  aid  in  making  a  diagnosis.  If  the  contours  of 
the  joint  are  not  obscured  by  such  a  swelling,  the  first  thing  that 
attracts  attention  is  the  marked  shortening  of  tiie  whole  extremity. 
The  joint  is  generally  slightly  flexed,  seldom  comj^letely  extended  ; 
the  forearm  is  sh'ghtly  supinated,  or  half-way  between  pronation  and 
supination.  The  axes  of  the  arm  and  forearm  do  not  meet  in  the 
joint,  but  a  little  behind  that  of  the  former.  A  careful  study  of  the 
important  /andmarks,  the  epicondyles  and  tip  of  the  olecranon,  is  of 
the  Jitniost  7'alue,  as  their  relative  positions  are  ahvays  seriously  altered 
in  this  form  of  dislocation.      The  anteroposterior  diameter  of  the  joint 


Fig.  402. — Complete  dislocation   of  both 
bones  of  the  forearm  backward. 


6o2 


DISLOCATIONS. 


is  always  markedly  increased.  The  tendon  of  the  triceps  is  very 
prominent,  and  can  be  readily  seen  and  felt  in  the  form  of  a  curve 
with  the  concavity  directed  backward.  On  both  sides  of  the  tendon 
there  is  a  marked  recession  of  the  skin.  The  olecranon,  the  sig- 
moid fossa  of  the  ulna,  and  the  head  of  the  radius  are  very  promi- 
nent behind — so  much  so  that  the  cup-shaped  depression  of  the 
articular  surface  of  the  radius  can  readily  be  felt.  The  cubital  fold 
of  the  elbow  is  displaced  downward.  Above  it  can  be  seen  and  felt 
a  distinct  and  almost  characteristic  swelling,  representing  the  lower 
end  of  the  humerus.  The  relation  of  the  olecranon  to  the  epicon- 
dyles  has  been  materially  changed.  If  the  forearm  is  extended,  the 
olecranon  is  above  the  epicondyles  ;  wJien  flexed,  behind  the  epicon- 
dyles.  The  olecranon  can  be  satisfactorily  palpated  at  a  point  from 
an  inch  and  a  half  to  two  inches  above  the  epicondyles.      In  rare 


Fig.  403- — Dislocation  of  radius  and  ulna  backward,  showing  position  of  the  ends  of 
the  dislocated  bones,  deformity  of  elbow,  and  position  of  forearm  (Hoffa). 


cases  the  forearm  is  displaced  slightly  outward.  In  such  cases  the 
elongated  axis  of  the  humerus  no  longer  strikes  the  ulna,  but  passes 
outward  or  inward  of  the  same. 

In  examining  into  the  functions  of  the  injured  joint,  it  is  found 
that  passive  flexion  and  extension  are  reduced  to  within  very  nar- 
row limits.  In  full  extension  lateral  mobility  is  increased.  Prona- 
tion and  supination  of  the  forearm  are  also  materially  impaired.  If 
an  attempt  be  made  to  rotate  the  forearm,  a  springy  resistance  is 
plainly  recognized.  Paresis,  varying  in  location  and  extent,  trace- 
able to  pressure  on  the  nerves,  is  a  common  symptom.  A  fracture 
of  the  coronoid  process  must  be  suspected  if  reduction  and  redis- 
location  are  accomplished  with  ease. 

The  symptoms  of  a  partial  dislocation  differ  from  those  of  a 
complete  one  only  in  degree. 


TREATMENT. 


603 


Treatment. — Before  any  attempts  are  made  to  reduce  a  poste- 
rior dislocation  of  both  bones  of  the  forearm,  it  is  of  the  utmost 
importance  to  ascertain  the  location  and  nature  of  the  resistances. 
The  fixation  of  the  coronoid  process  in  its  faulty  position  is  caused 
by  the  untorn  portions  of  the  capsular  and  lateral  ligaments,  and 
especially  by  the  twisted  radiating  firm  fascia  of  the  forearm  on  the 
dorsal  side,  which  extends  to  the  muscles  attached  to  the  condyles 
of  the  humerus.  Interposition  of  soft  tissues,  fragments  of  the  torn 
capsule  and  muscles,  especially  the  brachialis  anticus,  and  avulsed 
bony  prominences  between  the  articular  surfaces  deserve  careful 
attention  as  causes  of  resistance  to  successful  reduction. 

In  recent  cases  reduction  is  made  without  any  special  difficulties. 
Aided  by  a  general  anesthetic,  the  reposition  can  often  be  made  by 
pressure  alone.  P'orced  flexion  is  the  oldest  method  of  reduction. 
The  forearm  is 
flexed  at  a  right 
angle,  when  ex- 
tension is  made 
by  an  assistant. 
While  this  is 
being  done,  the 
physician  places 
his  forearm  in 
the  bend  of  the 
elbow,  which 
constitutes  a 
f  u  1  c  r  u  m ,  over 
which  the  dis- 
placed coronoid 
process  is  lifted 
into  its  proper 
place,  assisted 
by  the  other 
hand     making 

pressure  over  the  olecranon.  The  reduction  is  usually  aiuiounced 
by  a  distinct  movement  and  snap  the  moment  the  articular  surfaces 
are  restored  to  their  normal  relations.  Instead  of  the  forearm,  the 
knee  can  be  u.sed  as  a  fulcrum. 

Dumrcicher's  distraction  method  is  more  rational  and  successful. 
The  patient  i.s  placed  on  a  table.  An  assistant  behind  the  patient 
makes  counterextcnsion  by  making  traction  on  a  sling  i)laced  in  the 
axilla  ;  a  second  assistant  grasps  the  arm  and  assists  in  making  the 
counterextcnsion.  The  physician  grasps  the  forearm  above  the 
wrist,  and  flexes  it  to  a  right  angle,  which  brings  the  coronoid 
process  lower  down,  and,  by  making  traction  upon  the  forearm  at 
its  base  away  from  the  body  with  the  aid  of  a  sling,  the  coronoid 
process  is  lifted  still  lower  down.  As  soon  as  he  feels  that  the 
process  is  liberated,  the  forearm  is  extended  while  extension  is  being 


Fig.  404. — Reduction  of  posterior  dislocation  of  both  bones 
of  the  forearm  by  flexion  and  extension  over  fulcrum,  aided  by 
pressure  (Hoffa). 


6o4 


DISLOCATIONS. 


made,  when  reduction  is  generally  effected,  attended  by  indications 
that  leave  no  doubt  as  to  the  result  of  the  operation.  The  most 
reliable  of  these  indications  is  the  possibility  of  acute  flexion  ivithont 
opposition. 


Fig.  405. — Reduction  of  posterior  dislocation  of  the  elbow  by  flexion,  using  the  knee  as 

a  fulcrum  (Hoffa). 


Fig.  406.— Dumreicher's  method  of  reduction  of  posterior  dislocation  of  the 
elbow-joint  (Hoffa). 

Roser  has  recommended  hyperextension  as  the  most  effective 
method  of  reducing  a  posterior  dislocation  of  the  elbow-joint. 
With  the  patient  in  the  recumbent  position,  the  operator  places  the 
injured  arm  upon  his  knee,  makes  hyperextension  until  the  arm  and 


TREATMENT. 


605 


forearm  form  an  angle  open  behind,  then  makes  rapid  flexion  com- 
bined with  extension.  During  these  movements  reposition  gener- 
ally takes  place.  It  is  advisable  to  have  an  assistant  make  pressure 
against  the  tip  of  the  olecranon  process  at  the  same  time  that  the 
operator  brings  the  forearm  from  the  hyperextended  into  a  flexed 
position. 

An  extensive  clinical  experience  has  demonstrated  that  the 
hyperextension  method  is  unattended  by  any  danger  of  injury  to  the 
important  soft  structures  on  the  flexor  side  of  the  bend  of  the  elbow. 
In  old  dislocations  that  can  not  be  reduced,  the  forearm  should  be 
flexed,  under  the  influence 
of  an  anesthetic,  sufficiently 
to  bring  it  into  a  useful 
position,  and  in  some  cases 
an  arthrotomy  or  resection 
of  the  joint  will  yield  a 
more  satisfactory  functional 
result. 

Forward  dislocation  of 
both  bones  of  the  forearm 
is  a  very  rare  accident. 
Until  recently  only  twenty- 
one  cases  of  this  kind  had 
been  recorded.  In  seven 
of  these  the  dislocation  was 
compound,  and  in  six  of 
these  seven  the  olecranon 
was  fractured.  Dislocation 
in  this  direction,  without 
fracture  of  the  olecranon, 
can  occur  only  if  the  dis- 
location occurs  with  the 
forearm  in  a  hyperextended 
position.  When  the  dislo- 
cation takes  place  with  the 
forearm  flexed,  fracture  of 
the  olecranon  process  al- 
ways complicates  the  inj  ury. 

In  most  cases  forward  dislocations  are  caused  by  direct  violence 
inflicted  upon  the  back  of  the  flexed  elbow.  The  experiments  of 
Colson  have  shown  that  fracture  of  the  olecranon  process  consti- 
tutes a  frequent  complication  of  dislocation  of  the  elbow  in  the 
anterior  direction.  Strcubcl  has  shown  that  anterior  dislocations 
are  occasionally  produced  by  violent  rotation  of  the  forearm  upon 
the  axis  of  the  humerus.  As  in  posterior  dislocations,  the  displace- 
ment of  the  articular  ends  may  be  partial  or  complete.  In  incom- 
plete dislocations  the  olecranon  occupies  only  a  part  of  the  troch- 
lea ;    in   complete,   the   entire    trochlea.       Complete    dislocation   is 


Fig.  407. — Complete  anterior  dislocation  of  both 
bones  of  the  forearm  (Iloffa). 


6o6 


DISLOCATIONS. 


made  possible  only  when  the  ligaments  are  extensively  lacerated, 
when  the  tendon  of  the  triceps  is  placed  in  a  condition  of  utmost 
tension,  and  when  the  brachialis  anticus  is  extensively  torn. 

Symptoms. — In  incomplete  anterior  dislocations  the  forearm  is 
elongated  about  an  inch  and  a  half  or  two  inches.  The  antero- 
posterior diameter  of  the  joint  is  diminished,  and  the  olecranon  is 
abnormally  prominent.  The  fold  on  the  flexor  side  of  the  joint  is 
not  appreciable.  The  empty  fossa  of  the  olecranon  can  be  felt,  and 
if  the  joint  is  not  much  swollen,  the  coronoid  process  can  be  seen 
and  felt.      On  the  outer  side  of  the  joint  the  head  of  the  radius  can 

be  seen.  Between  the  ulna,  ra- 
dius, and  processus  cubitalis  a 
ring-like  furrow,  created  by  the 
soft  tissues  in  a  state  of  tension, 
can  be  seen  and  felt.  The  fore- 
arm is  either  extended  or  mod- 
erately flexed. 

In  complete  dislocations  the 
lower  end  of  the  humerus  lies 
behind  and  immediately  under- 
neath the  skin.  If  the  olecranon 
is  fractured,  the  anteroposterior 
diameter  of  the  joint  is  increased, 
and  the  forearm  is  slightly  flexed 
and  supinated  and  considerably 
shortened.  The  tip  of  the  olec- 
ranon retains  its  normal  posi- 
tion, but  the  base  is  abnormally 
swollen.  Over  the  line  of  fracture 
is  a  deep  depression.  Further- 
more, additional  evidences  of 
fracture  present  themselves. 
Reposition  is  generally  easily 
effected.  It  is  made  by  moder- 
ate extension  and  direct  pressure 
from  before  backward,  upon  the 
ulna  and  radius,  and  from  behind 
forward  upon  the  lower  end  of  the  humerus.  The  reduction  can 
also  be  accomplished  by  strong  flexion  of  the  forearm  and  back- 
ward pressure  upon  the  dislocated  ends  of  the  radius  and  ulna. 

Lateral  luxations  of  the  forearm  are  very  uncommon.  It  has 
been  found  that  lateral  dislocations  are  usually  attended  by  more 
or  less  posterior  displacement.  In  the  great  majority  of  cases  the 
dislocation  is  incomplete,  and  takes  an  outward  direction  much 
more  frequently  than  the  opposite.  This  is  owing  to  the  greater 
resistance  offered  to  the  dislocating  force  by  the  inner  than  by  the 
outer  side  of  the  joint.  The  patients  are  usually  children  in  whom 
the  resistance  of  the  joints  has  not  been  fully  developed,  owing  to 


Fig.  408. — Outward  and  backward  dislo 
cation  of  both  bones  of  the  forearm. 


LATERAL    LUXATIONS. 


607 


the  absence  or  incomplete  dev^elopment  of  the  bony  prominences 
wliich  contribute  so  much  to  the  strength  of  the  joint. 

This  dislocation  is  caused  by  a  fall  upon  the  hand,  with  extended 
or  moderately  flexed  forearm,  or  a  fall  upon  the  arm  itself  or  the 
elbow.  The  mechanism  of  the  production  of  the  dislocation  from  a 
fall  upon  the  hand,  according  to  Hueter,  is  the  same  as  in  posterior 
luxations.  The  secondary  movement  in  these  cases  is  not  flexion, 
but  lateral  deviation.  At  the  moment  of  rupture  of  the  capsule  the 
body  loses  its  support  by  the  loss  of  bone  contact,  and  the  bones 
are  displaced  laterally.  Violent  abduction  or  adduction  may  cause 
lateral  dislocation.  If  the  forearm  is  forcibly  adducted  and  force 
is  applied  to  the  inner  surface  of  the  ulna,  an  outward  dislocation 
is  very  liable  to  occur,  and  the  same  forces  applied  in  an  opposite 
direction  may  result  in  an  inward  dislocation. 

In  complete  inward  dislocations  the  olecranon  fossa  lies  below, 
and  embraces  the  internal  condyle.      The  radius  is  found  in  front 


Fig.  409. — Incomplete  inward  dislocation  of  the  elbow  (Hoffa). 


of  and  somewhat  below  the  trochlea.  Both  lateral  ligaments  are 
torn.  The  forearm  is  pronated  and  lightly  flexed.  The  olecranon 
and  external  cond\'le  are  pretcrnaturally  prominent.  The  head 
of  the  radius  is  felt  below  and  to  the  inner  side  of  its  position.  In 
incomplete  inward  dislocations  the  same  .symptoms,  though  less 
marked,  present  themselves.  Flexion  and  extension  can  be  made, 
and  are  not  attended  by  much  pain.  In  unreduced  dislocations  of 
this  kind  the  function  of  the  limb  is  not  much  impaired.  In  external 
luxations  the  internal  lateral  ligament  is  not  always  torn,  but  the 
internal  epicondyle  is  frequently  detached,  by  contraction  of  the 
flexor  or  prtjnator  radii  teres,  or,  what  is  more  often  the  case,  by 
a  blow  which  at  once  relieves  the  traction  upon  the  ligament. 

If,  in  the  cadaver,  the  internal  condyle  is  detached,  hypcrextension 
results  in  outward  luxation,  as  has  been  shown  by  the  e.xperiments 
of  Sprcngcl.    In  both  lateral  displacements  the  capsule  is  extensively 


6o8 


DISLOCATIONS. 


lacerated  in  front,  as  well  as  behind,  and  the  para-articular  struc- 
tures are  more  or  less  injured  at  the  same  time.  Of  the  nerves,  the 
ulnar  suffers  most.  All  lateral  luxations  are  attended  by  severe 
injury  to  the  soft  structures  composing  the  joints  and  the  tissues 
outside  of  it. 

In  incomplete  outward  luxations  of  the  elbow-joint  the  following 
points  are  to  be  noted  :  The  lateral  displacement  takes  place  so  far 
that  the  central  longitudinal  ridge  of  the  olecranon  fossa  has  passed 
beyond  the  outer  rim  of  the  trochlea.  The  radius  lies  partly  below 
or  entirely  beyond  the  external  condyle.  The  elbow  is  more  or 
less  flexed,  and  the  forearm  is  pronated.  The  internal  condyle  is 
prominent,  the  skin  being  tightly  stretched  over  it.     The  external 

condyle  is  very  prominent,  the  olecra- 
non is  conspicuous,  and  the  tendon  of 
the  biceps  is  curved.  The  head  of  the 
radius  can  be  distinctly  felt  and  outlined. 
In  complete  outward  dislocation 
the  symptoms  are  unmistakable.  The 
bones  of  the  forearm  are  displaced  so 
far  in  an  outward  direction  that  they 
appear  not  to  be  in  contact  with,  but 
entirely  outside  of,  the  humerus.  On 
the  outer  side  of  the  joint  can  be  seen 
the  prominent  head  of  the  radius  ;  on 
the  inner  side,  the  internal  condyle  of 
the  humerus,  the  displacements  being 
so  great  that  the  lateral  diameter  of 
the  joint  is  doubled.  The  skin  over 
the  internal  aspect  of  the  lower  end  of 
the  humerus  is  stretched  so  tightly  that 
the  contour  of  the  bone  can  be  very 
readily  observed. 

Three  grades  of  outward  dislocation 
are  recognized  and  described.  In  ex- 
treme cases  the  bones  of  the  forearm 
override  the  outer  border  of  the  humerus.  In  the  complete  variety 
the  head  of  the  radius  is  so  prominent  that  the  depression  in  the 
articular  surface  can  be  seen  and  felt.  The  forearm  is  either  flexed 
or  extended  in  a  strongly  pronated  position. 

Treatment. — Reposition,  owing  to  the  extensive  laceration  of  the 
capsular  ligament,  is  usually  easy.  In  outward  luxations  extension 
is  made  on  the  hand  and  forearm,  with  pressure  over  the  latter  in- 
ward, and  over  the  arm,  outward.  If  this  attempt  does  not  suc- 
ceed, it  is  very  probable  that  either  the  epicondyle  or  the  tendon  of 
the  biceps  has  become  interposed.  It  is  well  in  such  cases  to  ab- 
duct the  hyperextended  forearm  and  follow  with  a  rapid  adduction, 
combined  with  pressure  against  the  arm  outward  and  the  forearm 
inward.     Instead  of  these  manipulations  the  joint  can  be  flexed,  so 


Fig.  410. — Complete  outward  dis- 
location of  the  elbow  (Hoffa). 


DISLOCATIONS    OF    ONE    BONE    OF    THE    FOREARM.  609 

that  the  reduction  can  be  made  during  h)-perextension,  abduction, 
rapid  adduction,  and  flexion  of  the  forearm.  If  the  detached 
epicond}-le  interfere  Avith  the  reduction  after  all  these  manoeuvers, 
it  must  be  removed  under  strict  aseptic  precautions. 

The  reposition  of  internal  dislocations  is  made  by  extension  and 
counterextension,  with  simultaneous  impulsion  of  the  articular  ends 
by  hyperextension,  adduction,  and  flexion  of  the  forearm. 

1.   Diverging  Dislocations  of  Both  Bones  of  the  Forearm. 

These  dislocations  are  very  rare,  as  is  seen  from  the  fact  that,  until 
quite  recently,  only  twelve  cases  were  recorded,  and  of  these  only 
one  was  transverse.  The  anteroposterior  variety,  the  only  one  of 
practical  interest,  is  produced  by  the  same  mechanism  as  produces 
posterior  dislocations,  but  with  the  divergence  of  the  two  bones, 
which  can  occur  only  after  extensive  laceration  of  the  interosseous 
ligament. 

The  ulna  is  found  behind,  and  the  radius  in  front  of,  the  articu- 
lar end  of  the  humerus.  In  the  transverse  form  the  olecranon  lies 
behind  the  epitrochlea,  and  the  radius  on  the  outer  surface  of  the 
external  condyle.  The  only  case  of  this  kind  was  observed  and 
described  by  Bisell  and  Guersant. 

Anteroposterior  divergent  dislocation  of  the  elbow  is  produced 
by  forcible  abduction  of  the  forearm.  The  elbow-joint  is  greatly 
widened  in  its  anteroposterior  diameter,  and  the  forearm  is  short- 
ened and  supinated.  The  olecranon  can  be  seen  and  felt  behind  the 
head  of  the  radius  in  front.  Each  bone  must  be  reduced  separately. 
In  two  of  the  cases  so  far  reported  reduction  failed,  and  in  one  only 
the  ulna  could  be  replaced. 

2.  Dislocations  of  One  Bone  of  the  Forearm. — Dislocations  of 
the  Ulna. — As  an  isolated  injury,  dislocation  of  the  ulna  is  very 
rare  and  can  take  place  backward  or  backward  and  inward.  In 
incomplete  dislocations  the  coronoid  process  is  displaced  only 
slightly  inward  and  backward,  over  the  margin  of  the  trochlear 
eminence.  In  complete  luxations  the  coronoid  process  is  engaged 
in  the  olecranon  fossa.  In  partial  dislocation  only  the  internal 
lateral  ligament-is  torn  ;  in  the  complete  variety  the  annular  ligament 
also  is  ruptured. 

The  dislocation  is  caused  by  a  fall  upon  the  ulnar  side  of  the 
hand  or  forearm,  whereby  the  extended  arm  is  abducted  and,  the 
force  continuing,  the  internal  lateral  ligament  gives  way,  the  dis- 
placement following.  The  ulna  can  be  dislocated  also  by  forced 
adduction  and  pronation,  especially  if,  at  the  same  time,  force  is  ap- 
plied to  the  hand  in  the  direction  of  the  joint,  or  if  forward  pressure 
is  made  upon  the  posterior  surface  of  the  humerus. 

The  symptoms  of  dislocation  of  the  ulna  resemble  very  much 
those  of  dislocation  of  both  bones  backward.  The  forearm  is 
usually  in  full  extension  and  adducted.  The  tendon  of  the  triceps 
is  preternatu rally  prominent,  and  a  deep  depression  is  seen  on  its 
inner,  and  a  more  shallow  one  on  its  outer,  side.  The  trochlea  is 
39 


6lO  DISLOCATIONS. 

prominent  in  front ;  the  olecranon,  behind.  The  inner  margin  of 
the  trochlea  is  very  conspicuous,  while  the  internal  epicondyle  is 
somewhat  obscured.  The  head  of  the  radius  is  in  its  normal 
position  or  slightly  displaced  inward.  The  shallow  angle  on  the 
outer  side  of  the  elbow,  formed  by  the  axes  of  the  humerus  and 
the  bones  of  the  forearm,  is  effaced,  and  sometimes  the  arm  is  so 
much  adducted  that  a  similar  angle  is  formed  on  the  opposite  side. 
The  ulnar  side  of  the  forearm  is  shortened.  The  forearm  is  hot 
only  adducted,  but  also  markedly  pronated.  Flexion  can  not  be 
made  beyond  a  right  angle,  and  is  very  painful ;  rotation  of  the 
forearm  is  free. 

In  incomplete  luxations  the  symptoms  are  the  same,  but  less 
pronounced.  The  local  symptoms  become  more  apparent  and 
positive  on  rotation  and  abduction  of  the  forearm  when  the  articular 
surfaces  between  the  ulna  and  humerus  are  more  widely  separated. 

In  the  reduction  of  this  dislocation  it  is  necessary  to  direct  the 
manipulations  in  such  a  way  that  they  will  dislodge  the  coronoid 
process  from  the  articular  depression,  and,  at  the  same  time,  relax 
the  posterior  untorn  portion  of  the  capsule.  An  attempt  is  first 
made  by  traction  upon  the  forearm  in  the  extended  position,  aided 
by  pressure  against  the  olecranon  process,  and,  if  the  reduction 
does  not  succeed,  the  forearm  is  hyperextended,  combined  with 
traction  and  local  pressure.  In  other  words,  the  reduction  is  made 
in  the  same  manner  in  which  the  accident  occurred,  the  arm  is 
hyperextended  and  abducted,  and  while  the  arm  is  rotated  outward, 
rapid  flexion  is  made. 

Dislocations  of  the  Radius. — Statistics  have  shown  that  luxa- 
tions of  the  radius  are  more  frequent  than  those  of  the  ulna,  as 
they  comprise  about  4  per  cent,  of  all  luxations.  Dislocation  of 
the  radius  as  an  isolated  injury  occurs  most  frequently  during  child- 
hood, as  in  adults  the  radiohumeral  joint  becomes  stronger  and 
more  secure  by  the  greater  firmness  of  the  ligaments  and  complete 
development  of  the  articular  prominences.  The  head  of  the  radius 
may  be  displaced  backward,  outward,  and  forward,  and  some  authors 
claim  also  downward.  These  dislocations  are  very  seldom  pro- 
duced by  direct  violence,  as  by  a  blow  upon  the  head  of  the  radius. 
Much  more  frequently  they  are  caused  by  the  transmission  of  force 
through  the  radius  by  a  fall  upon  the  hand  or  forearm.  Until 
recently  it  has  been  claimed  that  dislocations  of  the  radius  occur 
most  frequently  in  consequence  of  forced  pronation. 

The  mechanism  of  the  dislocation  was  explained  thus  :  In 
extreme  pronation  a  fulcrum  is  formed  where  the  radius  and  ulna 
cross  each  other,  and  the  radius  then  forms  a  lever  which,  at  its 
humeral  end,  under  the  influence  of  the  same  force,  ruptures  the 
capsule  and  causes  the  dislocation.  The  experiments  of  Schiiller 
and  Lobker  have  shown  conclusively  that  such  lever  action  is 
never  established  by  forced  pronation  in  the  adult  and  very  seldom 
in  children.      Forced  supination  occasionally  may  result  in  partial 


DISLOCATIONS    OF    THE    RADIUS.  6 II 

backward  luxation  of  the  radius  if  the  dislocating  force  first  tears 
off  the  epicondyle  in  connection  with  the  external  ligament.  If  the 
ulna  is  fractured  in  its  upper  third,  a  secondary  dislocation  of  the 
radius  is  readily  produced  by  hyperextension  or  forced  pronation. 

Forced  pronation  and  supination  play  an  important  part  in  the 
production  of  dislocations  of  the  head  of  the  radius  when  combined 
with  forced  adduction  or  abduction  of  the  forearm.  If,  when  the 
forearm  is  extended  or  slightly  flexed,  forced  pronation  is  made, 
and  at  the  same  time  the  arm  is  also  strongly  adducted  or  abducted, 
the  annular  ligament  tears,  or  the  head  of  the  radius  slips  out  of  it 
below,  and,  after  the  cessation  of  the  forced  movement,  presents 
itself  in  front,  behind,  or  to  the  outside  of  the  external  condyle  of 
the  humerus.  Forced  supination  combined  with  forcible  abduction 
produces  the  same  effects  and  the  same  kinds  of  dislocation.  The 
production  of  the  dislocations  is  favored  when  a  fragment  from 
the  radial  side  of  the  coronoid  process  is  broken  off  and  the  line 
of  fracture  extends  to  the  annular  ligament.  Undoubtedly  most  of 
the  dislocations  of  the  head  of  the  radius  are  produced  by  a  com- 
bination of  forced  pronation  and  abduction. 

The  direction  that  the  head  of  the  radius  takes  after  tearing  of 
the  annular  ligament  and  capsule  depends  mainly  on  the  direction 
of  the  dislocating  force  and  the  location  of  rupture  in  the  capsule. 
If  the  luxation  occur  forward,  the  annular  ligament  is  torn  ;  if 
backward,  the  posterior  portion  of  the  lateral  ligament ;  and  if  out- 
ward, not  only  the  annular  and  external  lateral,  but  also  the  inter- 
osseous. In  children  the  head  of  the  radius  can  also,  under  strong 
traction,  slip  from  the  grasp  of  the  annular  ligament,  and,  after  its 
liberation,  may  become  displaced  in  different  directions. 

Dislocations  of  the  head  of  the  radius  are  very  often  secondary 
to  fractures  of  the  upper  part  of  the  shaft  of  the  ulna,  coronoid 
process,  and  external  epicondyle.  If  the  dislocation'  is  the  result 
of  the  application  of  direct  force,  a  part  of  the  head  of  the  radius 
is  often  chipped  off,  but  as  the  fracture  is,  at  least  in  part,  extra- 
capsular, and  as  there  is  little  displacement,  union  by  bone  is  the 
rule.  Neither  does  the  fracture  materially  impair  the  functional 
result  if  the  dislocation  is  reduced  and  the  necessary  care  exercised 
during  the  after-treatment. 

Among  the  soft  tissues  that  are  liable  to  injur}-  in  dislocations  of 
the  radius  outside  of  the  ligaments  must  be  mentioned  the  supinator 
brevis,  the  brachialis  internus,  and  the  musculo.spiral  nerve. 

Backward  Dislocation. — The  head  of  the  radius  can  be  felt 
behind  the  external  condyle  and  on  the  side  of  the  olecranon 
process,  while  a  deep  de])ression  can  be  seen  and  felt  below  the 
external  condyle.  The  muscles  di.splaced  by  the  head  of  the  radius 
on  its  way  backward  hide  the  external  epicondyle,  while  the  internal 
e|)icondyle  is  very  prominent.  The  distance  between  the  external 
epicondyle  and  the  styloid  process  of  the  radius  is  diminished. 
The   forearm   is  abducted,   and   the  angle  at  the  elbow  increased. 


6l2 


DISLOCATIONS. 


The  forearm  is  in  a  position  half-way  between  pronation  and  supina- 
tion, and  can  not  be  extended  or  supinated.  Reduction  by  direct 
pressure  is  usually  successful,  and,  if  necessary,  is  aided  by  adduc- 
tion of  the  forearm  and  extension.  Failure  to  reduce  a  recent 
dislocation  is  usually  due  to  interposition  of  the  annular  ligament. 
Outward  Dislocation. — In  some  of  the  outward  dislocations  the 
inner  portion  of  the  head  of  the  radius  is  broken  off.  The  head  of 
the  radius  is  found  to  the  outer  side  of  the  external  condyle,  where 
it  appears  in  the  form  of  an  almost  characteristic  swelling,  while 
below  and  behind  the  external  condyle  a  marked  depression  can  be 
seen  in  which  the  articular  surface  of  the  condyle  can  be  distinctly 
outlined.  The  abnormal  position  of  the  head  of  the  radius  is 
determined  in  the  most  satisfactory  and  reliable  manner  by  extend- 
ing and  flexing,  alternately,  the  forearm,  and  at  the  same  time 
making  pronation  and  supination.     Rotation  of  the  forearm  is  not 


Fig.  411. — Forward  dislocation  of  the  head  of  the  radius  (Hoffa). 

much  impaired  in  outward  dislocation  of  the  head  of  the  radius. 
Reduction  is  most  readily  effected  by  alternate  adduction  and 
abduction  of  forearm,  aided,  if  necessary,  by  extension  and  direct 
pressure. 

Dislocation  Forivard. — This  is  the  most  common  form  of  dislo- 
cation of  the  head  of  the  radius.  It  is  frequently  accompanied  by 
fracture  of  the  shaft  of  the  ulna,  caused  by  a  fall  upon  the  hand. 
The  head  of  the  radius  is  displaced  forward  and  upward,  where  it 
presents  itself  in  front  of  the  external  condyle  of  the  humerus  as 
a  clearly  visible  and  palpable  swelling  underneath  the  supinator 
brevis  muscle.  A  distinct  depression  is  noticeable  behind  and  be- 
low the  external  condyle,  in  which  the  lateral  articular  depression 
of  the  ulna  can  be  felt  if  the  tendon  of  the  biceps  does  not  pass 
over  it.  The  swelling  in  the  bend  of  the  elbow  is  made  more  con- 
spicuous by  extending  the  forearm.      The  forearm  is  slightly  flexed, 


DOWNWARD    DISLOCATION.  613 

somewhat  pronated,  and  the  patient  is  unable  to  rotate  the  forearm 
or  flex  it  to  more  than  a  right  angle.  If  flexion  is  carried  further, 
it  is  arrested  by  the  head  of  the  radius  resting  against  the  anterior 
surface  of  the  humerus.  The  radial  side  of  the  forearm  is  short- 
ened, and  pronation  and  supination  are  limited  or  impossible.  The 
external  epicondyle  is  preternaturally  prominent. 

Reduction  is  sometimes  very  easy,  sometimes  impossible.  The 
best  method  of  reduction  of  a  forward  dislocation  of  the  radius  is  by 
abduction  of  the  forearm  and  direct  pressure.  In  fractures  of  the 
upper  part  of  the  shaft  of  the  ulna  this  dislocation  should  always  be 
looked  for. 

Malgaigne,  Hutchinson,  and  Lindemann  have  described  an  in- 
complete anterior  dislocation  of  the  head  of  the  radius  in  children. 
Streubel  and  others,  however,  believe  that  the  symptoms  that  have 
been  observed  in  such  cases  are  due,  not  to  a  dislocation,  but  to 
interposition  of  the  intact  posterior  portion  of  the  capsule  between 
the  articular  surfaces.  In  small  children  the  injury  is  caused  by 
lifting  them  by  the  pronated  hand.  The  function  of  the  arm  is 
suspended  at  once,  and  the  pain  is  greatly  aggravated  by  attempts 
to  correct  the  pronation.  If  the  bone  is  flexed  and  supinated,  a 
crackling  sensation  is  felt.  Almost  immediately  after  such  inter- 
ference the  child  resumes  the  use  of  the  arm.  To  guard  against 
recurrence  it  is  advisable  to  immobilize  the  limb,  with  the  arm  at  a 
right  angle,  for  at  least  a  week. 

Dozvmvard  Dislocation. — Downward  displacement  of  the  head 
of  the  radius  was  described  by  Duverney  in  175 1.  This  dis- 
location is  not  generally  recognized,  but  there  is  but  very  little 
doubt  that  such  cases  have  occurred.  It  has  been  observed  in  chil- 
dren less  than  three  years  of  age.  It  is  caused  by  traction  upon  the 
hand.  Tenderness  in  the  region  of  the  head  of  the  radius  and  a 
space  between  it  and  the  external  condyle  have  been  mentioned  as 
the  most  prominent  symptoms.  With  the  exception  of  supination, 
passive  motion  is  not  much  interfered  with  by  this  dislocation.  Re- 
duction is  effected  by  forced  supination,  the  return  of  the  head  of 
the  radius  to  its  normal  location  being  generally  announced  by  a 
distinct  click. 


CHAPTER   XIII. 

EXPLORATORY  PUNCTURE,  SUBCUTANEOUS  AND 
PARENCHYMATOUS  MEDICATION,  PARACENTE- 
SIS, AND  DRAINAGE  OF  SUPPURATING  JOINTS. 

The  hypodermic  and  exploratory  needles  and  trocars  of  various 
sizes  and  shapes  are  instruments  constructed  upon  the  same  plan, 
and  are  intended  to  reach  the  tissues  underneath  the  skin  for  diag- 
nostic purposes,  subcutaneous,  intra-articular,  and  parenchymatous 
medication,  and  to  remove  fluid  pathologic  products. 

The  extent  to  which  the  hypodermic  syringe  is  now  being  used 
in  the  practice  of  every  physician  and  surgeon  makes  it  desirable  to 
detail,  at  some  length,  the  proper  use  of  this  instrument ;  the  same 
remarks  apply  to  the  exploratory  needle  and  trocar.  Many  acci- 
dents have  occurred  from  the  employment  of  defective  needles.  The 
breaking  off  of  the  point  of  a  hypodermic  needle  in  the  tissues  is  a 
very  unpleasant,  and,  to  a  large  extent,  an  avoidable,  accident.     The 


Fig.  412.— Hypodermic  needle-points:    A,  Plain;  B,  reinforced;  C,  aspirating  needle  ; 

D,  hypodermic  trocar. 

strength  and  permeability  of  the  needle  must  be  carefially  tested, 
and  the  breaking  off  of  a  perfect  needle  must  be  guarded  against 
by  cautious  manipulation  of  the  instrument  and  by  securing,  before- 
hand, immobility  of  the  part  to  be  punctured.  In  the  case  of  chil- 
dren and  excitable,  nervous  persons  it  may  become  necessary  for  an 
assistant  to  steady  the  patient  while  the  physician  immobilizes  the 
part  to  be  punctured.  Hypodermic  needles  and  trocars  can  be  steril- 
ized in  a  reliable  manner  only  by  boiling  for  five  or  ten  minutes  in 
soda  solution.  Passing  the  needle  or  trocar  through  the  flame  of  an 
alcohol  lamp,  dipping  it  into  a  5  per  cent,  solution  of  carbolic  acid  or 
in  pure  carbolic  acid  or  alcohol,  as  is  so  frequently  done  as  an  excuse 
for  disinfection,  can  not  be  relied  upon  in  effecting  complete  steriliza- 
tion, as  microbes  buried  in  desiccated  blood,  secretions,  fat,  or  dirt  tvill 
escape  the  destructive  action  of  the  most  potent  chemic  a7ttiseptics. 

614 


INSTRUMENTS. 


615 


If  the  instrument  is  used  indiscriminately  among  different  patients, 
resterilization  is  necessary  in  going  from  one  patient  to  another,  as 
otherwise  there  is  danger  of  transmitting  disease  from  one  patient  to 
another.  If  a  patient  is  to  be  subjected  to  subcutaneous  or  parenchy- 
matous injections  for  any  considerable  length  of  time,  he  should  be 
supplied  with  an  instrument  of  his  own.  This  is  particularly  neces- 
sary if  he  is  the  subject  of  an  acute  infectious  disease,  such  as  syphilis 
or  tuberculosis.  The  conditions  for  infection  in  making  a  subcu- 
taneous injection  are  not  nearly  so  favorable  as  when  a  joint  is  punc- 
tured and  injected,  owing  to  the  rapidity  with  which  the  absorption 
of  fluids  from  the  subcutaneous  tissues  takes  place,  and,  with  it, 
the  rapid  disappearance  of  the  microbes  introduced. 


Fig.  413. — Koch's  hypodermic  syringe. 


Fig.  414. — Antitoxin  syringe. 


The  general  condition  of  the  patient  has  also  an  influence  in 
determining  infection  after  puncture,  as  the  resistance  of  the  tissues 
to  the  action  of  pathogenic  microbes  is  much  impaired  in  anemic 
and  badly  nourished  subjects.  The  correctness  of  this  assertion  is 
perhaps  best  illustrated  by  what  is  occasionally  seen  in  the  case  of 
morphin  or  cocain  habitues.  So  long  as  the  general  health  is  not 
much  impaired,  the  daily  use  of  a  dirty  syringe  may  cause  no 
.serious  con.sequences,  but  when  the  patient  becomes  marasmic  and 
anemic,  every  puncture  made  with  the  same  syringe  becomes  a 
focus  of  infection  in  the  form  of  a  furuncle  or  abscess.  I  have  seen 
a  number  of  such  instances. 


6l6  EXPLORATORY  PUNCTURE. 

The  use  of  a  dirty  hypodermic  syringe  has  in  many  instances 
been  followed  by  fatal  sepsis.  I  have  personal  knowledge  of  a  most 
distressing  case  of  this  kind.  The  father  of  a  young,  promising 
physician  suffered  from  a  painful,  but  in  no  way  dangerous,  affection. 
The  son  made  a  hypodermic  injection  of  morphin  with  a  syringe 
that  he  carried  with  him  on  his  daily  rounds.  The  patient  died  in 
a  very  few  days  with  symptoms  of  the  most  acute  form  of  sepsis 
that  had  its  starting-point  at  the  seat  of  puncture.  It  is  unneces- 
sary to  say  that  the  unfortunate  son  had  failed  to  sterilize  the  needle, 
and  that  he  keenly  felt  his  responsibility  when  the  fatal  complication 
made  its  appearance.  From  that  moment  his  mind  became  un- 
balanced, and  he  sought  relief  from  remorse  in  the  excessive  use 
of  alcoholic  stimulants,  and  in  a  few  years  found  what  he  had 
vainly  sought  for  during  life,  peace, — in  a  drunkard's  grave. 

Bouchard  relates  the  following  incident :  A  male  nurse  in  his 
employ  who  had  become  addicted  to  the  use  of  morphin  made  an 
iniection  with  a  syringe  that  had  not  been  properly  sterilized,  and 
erysipelas  developed  from  the  puncture.  In  the  evening  of  the  same 
day  the  assistant  physician  administered  an  injection  of  mor- 
phin, and,  with  the  same  instrument  and  without  sterilization,  in- 
jected four  tabetic  patients.  The  result  was  that  in  less  than  two 
days  all  of  them  became  victims  of  a  grave  form  of  erysipelas. 

Brieger  and  Ehrlich  reported  two  cases  of  typhoid  fever,  the 
patients  being  given  hypodermic  injections  of  tincture  of  musk  when 
in  a  condition  of  collapse.  The  same  syringe  and  solution  were 
used  in  both  cases,  and  in  both  of  them  a  purulent  edema  started 
from  the  point  of  puncture,  to  which  both  rapidly  succumbed. 

Fatal  phlegmonous  inflammation  caused  by  the  use  of  the  hypo- 
dermic syringe  has  occurred  repeatedly,  and  abscess  formation  is 
not  an  uncommon  occurrence.  Anthrax  has  been  communicated 
in  the  same  manner,  and  there  are  at  least  two  well-authenticated 
cases  in  which  tuberculosis  was  thus  conveyed.  These  cases  suf- 
fice to  bring  forcibly  to  our  attention  the  necessity  of  sterilizing  the 
hypodermic  syringe  and  of  using  sterile  solutions  in  the  subcutane- 
ous and  parenchymatous  administration  of  drugs  of  any  kind. 

Many  of  the  fluid  preparations  for  hypodermic  use  sold  by  drug- 
gists and  wholesale  manufacturers  are  not  sterile,  as  has  been  shown 
most  conclusively  by  the  painstaking  and  extensive  investigations 
made  by  Schimmelbusch  and  Hohl.  It  is  fortunate  that  some  of 
the  solutions  in  common  use,  such  as  ether  and  saturated  solution 
of  quinin,  destroy  the  ordinary  pus-microbes  at  once,  as  has  been 
shown  by  Ferrari.  In  a  lo  per  cent,  solution  of  cocain  pus- 
microbes  were  found  active  after  two  hours.  In  a  2  per  cent,  solution 
of  morphin  they  were  destroyed  after  twenty-four  hours.  In  glycerin 
the  staphylococci  lived  six  days.  In  a  i  per  cent,  solution  of 
atropin  and  a  0.5  to  i  per  cent,  solution  of  morphin  they  lived  for 
weeks  and  increased  in  number  to  an  extraordinary  degree.  These 
observations  only  tend  to  show  the  necessity  of  sterilizing  doubtful 


EXPLORATORY  PUNCTURE.  617 

solutions  and  of  preparing  fresh  solutions  whenever  it  is  possible  to 
do  so. 

Sterilization  and  resterilization  of  prepared  solutions  are  best 
done  by  exposure  for  a  sufficient  length  of  time  to  live  steam.  Con- 
tamination of  ready-made  solutions  can  be  prevented  to  a  great  ex- 
tent by  the  addition  of  carbolic  acid,  creasote,  or  bichlorid  of  mer- 
cury, even  in  ver}*  small  quantities. 

Koch's  syringe  is  an  excellent  instrument  for  subcutaneous 
medication.  Overlach's  piston  syringe  can  be  sterilized,  without 
damaging  the  instrument,  by  boiling.  The  leather  piston  has  been 
almost  entirel}'  replaced  by  asbestos.  Steel  needles  are  damaged 
b\'  dry  heat,  but  needles  made  of  platinum-iridium  can  be  treated 
in  this  manner  without  impairing  their  strength. 

Another  precaution  in  the  prevention  of  infection  from  needle 
puncture  is  disinfection  of  the  skin,  which  should  never  be  omitted. 
This  can  be  accomplished  effectually  and  speedily  by  scrubbing  with 
hot  water  and  soap,  followed  by  rubbing  the  surface  with  absolute 
alcohol  or  a  5  per  cent,  solution  of  carbolic  acid.  If  it  is  the  inten- 
tion to  introduce  the  solution  underneath  the  skin,  a  fold  of  the  skin 
is  raised  and  the  needle  inserted  boldly  into  the  loose  connective 
tissue,  when  the  fluid  is  injected  somewhat  slowly,  so  as  to  bring  it 
in  contact  with  a  maximum  surface  for  absorption.  /;/  makhig  a 
pare7icJiymatoiis  injection,  the  needle  is  inserted  into  the  sivelling  or 
tumor,  a?td  before  the  injection  is  made,  tlic  point  is  ivitlidrawn  a  lijie 
or  tii'o  to  prevent  entrance  of  the  solution  directly  into  the  circidation 
in  case  the  point  of  the  needle  should  hare  penetrated  a  vein. 

In  making  a  copious  parenchymatous  injection,  the  contents  of 
the  syringe  are  injected  slowly  as  the  needle  is  being  withdrawn,  and 
as  soon  as  the  point  of  the  instrument  is  near  the  skin,  the  direction 
of  the  needle  is  changed  and  another  puncture  made,  when  the 
syringe  is  detached,  filled  with  the  solution,  and  again  connected 
with  the  needle,  and  the  injection  made  as  before.  In  this  manner 
several  syringefuls  can  be  injected  into  the  pathologic  product 
through  the  same  puncture  in  the  skin. 

The  injections  of  a  tumor  or  any  other  pathologic  product  to 
the  extent  just  described  results  in  more  or  less  tension,  which 
makes  it  desirable  to  seal  the  puncture  hermetically  with  a  film  of 
cotton  or  collodion. 

Exploratory  puncture  is  made  exclusively  for  diagnostic  pur- 
poses, and  if  the  pathologic  product  is  fluid  and  within  reach  of  the 
needle  of  an  ordinary  hypodermic  syringe,  this  instrument  answers 
all  the  requirements.  Exploration  of  the  subdural  space,  peri- 
cardium, pleural  cavity,  and  more  superficial  accumulations  of  serum 
or  blood  can  be  done  in  a  reliable  manner  by  the  use  of  the  hypo- 
dermic syringe.  The  puncture  should  always  be  made  obliquelj' 
and  under  .strictest  aseptic  precautions,  to  guard  against  leakage  and 
later  infection.  By  making  the  puncture  obliquely  the  valvular 
arrangement  in  the  wall  of  the  cavity  e.xploreci  will  prevent  cxtrava- 


6i8 


EXPLORATORY  PUNCTURE. 


sation  and  serve  as  a  mechanical  barrier  to  the  subsequent  entrance 
of  pathogenic  microbes.  The  direction  of  the  needle  from  the  sur- 
face to  the  cavity  to  be  explored  must  be  determined  beforehand, 
and  when  this  has  been  done,  the  needle  is  plunged  to  its  destination 
in  one  quick  movement.  As  soon  as  resistance  ceases,  it  is  a  sure 
indication  that  the  point  of  the  needle  has  reached  the  space  to  be 
explored,  when  aspiration  is  made  and  the  result  carefully  noted. 
If  the  cavity  contain  a  substance  sufficiently  fluid  to  flow  through 
the  narrow  lumen  of  the  needle,  such  as  blood  or  serum,  the  result 
of  the  puncture  will  yield  the  desired  diagnostic  information.  If  the 
cavity  is  small  and  distant  from  the  surface,  it  often  becomes  neces- 
sary to  make  systematic  explorations  by  pushing  the  needle  from 
the  same  external  puncture  in  different  directions,  and  making  aspi- 
ration at  different  points  as  the  needle  is  advanced  or  withdrawn. 


Fig.  415- — Large  hypodermic  syringe  with  stop-cock,  used  for  exploratory  purposes. 


This  method  of  exploration  is  the  one  to  be  recommended  in  treat- 
ing pulmonary  and  cerebral  abscesses.  Thin,  sanious  pus  will  escape 
through  the  needle  of  an  ordinary  hypodermic  syringe,  but  mucus, 
thick,  creamy  pus,  and  the  contents  of  a  tubercular  abscess  usually 
require  the  larger  needle  of  an  exploratory  syringe  to  demonstrate 
their  presence  in  the  swelling  under  examination. 

An  exploratory  syringe  differs  from  a  hypodermic  syringe  only 
in  size.  The  glass  cylinder,  piston,  and  needles  are  larger.  The 
needles  vary  in  size  from  the  needle  of  an  ordinary  hypodermic 
syringe  to  that  of  a  small-sized  trocar.  The  increased  length  of  the 
needles  enables  the  surgeon  to  reach  fluid  pathologic  products 
beyond  the  range  of  the  hypodermic  syringe.  Every  physician 
should  have  and  maintain  in  good  condition  an  exploring  syringe, 


EXPLORATORY  PUNCTURE.  619 

which  is  used  solely  for  diagnostic  purposes,  reserving  the  use  of 
the  hypodermic  needle  for  the  subcutaneous  or  parenchymatous  ad- 
ministration of  therapeutic  agents.  As  the  exploring  syringe  is  used 
almost  exclusively  for  the  demonstration  of  the  presence  and  nature 
of  pathologic  products,  careful  disinfection  by  boiling  in  soda  solu- 
tion for  five  or  ten  minutes  after  each  use  becomes  absolutely  neces- 
sary. 

In  the  exploration  of  doubtful  fluctuating  swellings  or  tumors 
of  the  abdominal  cavity,  the  greatest  care  is  required  either  in  ex- 
cluding the  free  peritoneal  cavity  from  the  line  of  puncture,  or  in 
making  the  puncture  sufficiently  oblique  with  a  small  needle  to 
prevent  extravasation  into  the  peritoneal  cavity.  Puncture  of  a 
distended  paretic  intestine  is  attended  by  great  risk  of  extravasa- 
tion and  should  be  avoided.  The  same  caution  applies  to  the  intra- 
peritoneal puncture  of  abscess  cavities.  Exploratory  puncture  of 
the  skull  for  suspected  hydrocephalus  in  young  children  is  made 
Avith  a  fine  needle,  through  existing  defects  in  the  skull,  the  fonta- 
nels, or  patent  sutures.  The  pericardium  is  punctured  in  the  fourth 
intercostal  space,  about  an  inch  distant  from  the  sternal  border. 
The  pleural  cavit}'  is  explored  by  puncturing  an  intercostal  space 
over  the  area  of  dullness,  obliquely  from  below  upward  and  inward, 
in  the  direction  corresponding  with  the  space  between  the  adjoining 
ribs.  In  doing  so  and  by  following  the  middle  of  the  intercostal 
space,  the  intercostal  vessels  and  nerve  are  avoided.  Before  mak- 
ing the  puncture  the  patient  should  be  placed  in  a  proper  position, 
either  sitting  or  in  a  half-reclining  posture,  with  the  arms  well 
elevated,  to  increase  the  width  of  the  intercostal  space.  The  best 
guide  for  the  needle  is  the  tip  of  the  left  index-finger,  which  is 
pushed  between  the  ribs  as  far  as  possible.  The  needle  is  then 
made  to  rest  against  the  radial  side  of  the  finger,  and  when  in 
proper  position,  is  pushed  through  the  chest-wall  in  one  move- 
ment. Even  local  anesthesia  is  unnecessary  in  such  cases,  as  when 
the  puncture  is  made  properly  and  with  the  necessary  quickness, 
the  pain  is  momentary  and  slight.  During  the  aspiration  the 
needle  should  be  held  steadily  in  the  position  in  which  it  was  in- 
serted. 

In  cases  in  which  the  cavity  punctured  is  very  tense,  the  dan- 
ger of  extravasation  through  the  needle  puncture  is  very  much  dimin- 
ished by  evacuating  a  part  of  its  contents  through  the  exploring 
needle.  This  can  be  done  by  detaching  the  syringe  from  the  needle 
if  the  extravasation  or  inflammatory  product  is  sufficiently  thin  to 
escape  through  the  needle  ;  otherwise  by  aspiration  with  the  syringe. 

P'or  good  reasons  the  old-fashioned  grooved  exploring  needle 
is  almost  entirely  out  of  use  and  has  been  replaced  by  the  tubular 
needle.  The  different  kinds  of  aspirators  in  such  common  use  but 
a  few  years  ago  as  diagnostic  instruments  are  seldom  employed  at 
the  present  time  for  such  purpose,  and  for  therapeutic  use  they 
have  been  replaced  largely  by  the  trocar  and  siphon. 


620  EXPLORATORY  PUNCTURE. 

It  is  to  be  hoped  that  the  profession,  as  a  whole,  will  soon 
realize  the  importance  of  strict  aseptic  precautions  in  the  employ- 
ment of  the  exploring  needle  as  a  diagnostic  instrument,  as  its 
reckless  and  careless  use  in  the  past  has  but  too  frequently  been 
followed  by  infection,  and,  in  the  case  of  infected  swellings,  mixed 
infection.  It  is  an  instrument  of  indispensable  diagnostic  value 
in  many  cases,  but  if  used  improperly,  it  becomes  a  dangerous 
weapon.  The  contents  of  the  syringe  in  successful  exploratory 
puncture  are  often  subjected  to  microscopic  and  bacteriologic  ex- 
amination for  further  diagnostic  information,  and  for  this  reason,  if 
for  no  other  and  more  important  one,  the  instrument  should  be 
absolutely  aseptic. 

Paracentesis. — This  operation  consists  of  tapping  any  of  the 
preformed  cavities  of  the  body  for  the  evacuation  of  fluid.  The 
operation  is  usually  performed  for  the  removal  of  an  extravasation 
(blood),  transudate  (serum),  or  the  product  of  a  suppurative  inflam- 
mation (pus).  The  evacuation  of  an  extravasation  or  a  transudate 
by  this  method  often  suffices  to  effect  a  permanent  cure,  while  the 
removal  of  pus  affords  only  temporary  relief  and  must  be  followed 
sooner  or  later  by  a  radical  operation.  The  aspirator,  used  so  ex- 
tensively as  a  substitute  for  the  trocar  during  the  last  two  decades, 
is  seldom  employed  at  the  present  time.     It  is  impossible  to  estimate 


Fig.  416. — Plain  trocar. 

the  suction  force  of  the  different  aspirators,  which  has  done  so  much 
harm  in  evacuating  the  different  cavities  after  the  removal  of  the  posi- 
tive pressure.  Great  vascular  engorgement,  hemorrhage,  edema, 
syncope,  and  distressing  cough  are  some  of  the  complications 
caused  by  harmful  aspiration,  according  to  the  nature  of  the 
cavity  and  its  contents  and  the  amount  of  suction  force  employed. 

The  proper  instruments  for  paracentesis  are  trocars  of  different 
sizes,  and  in  cases  in  which  simple  tapping  is  liable  to  be  at- 
tended by  the  entrance  of  air,  a  piece  of  rubber  tubing  is  attached 
to  the  cannula  of  the  trocar,  the  fluid  being  evacuated  by  siphonage. 
The  entrance  of  air  after  the  positive  pressure  is  removed  is  pre- 
vented by  immersing  the  free  end  of  the  rubber  tube  in  a  nontoxic 
antiseptic  solution.  For  this  purpose  trocars  without  shields  must 
be  used. 

As  punctured  wounds  are  very  easily  infected,  the  operation 
must  be  performed  under  the  most  pedantic  aseptic  precautions.  The 
trocar  is  sterilized  by  boiling  in  soda  solution  for  at  least  from  five 
to  ten  minutes.  The  hands  and  point  of  puncture  are  disinfected 
with  the  same  care  as  is  used  in  the  preparations  for  any  other  oper- 
ation. General  anesthesia  is  never  permissible,  as  the  pain  caused 
by  the  puncture  is  of  only  momentary  duration,  and  in  enfeebled  or 


HYDROCEPHALUS.  621 

nervous  subjects  can  be  almost  entirely  obviated  by  freezing  the 
skin  with  ether  or  chlorid  of  ethyl  spray.  TJic  tunnel  made  by  the 
trocar  in  the  deep  tissues  should  never  correspond  with  the  puncture  in 
the  skin,  as  otherzuise  subsequent  leakage  and  infection  might  occur. 
The  tubular  wound  in  the  deep  tissues  is  made  subcutaneously  by 
making  the  puncture  obliquely,  or  by  displacing  the  skin  by  draw- 
ing it  to  one  side  before  the  puncture  is  made.  After  the  cannula  is 
withdrawn,  the  puncture  in  the  skin  is  sealed  wath  collodion  and  a 
thin  film  of  sterile  absorbent  cotton,  which  remains  in  place  until  the 
continuity  of  the  skin  is  restored  by  healing  of  the  little  wound. 

Hydrocephalus. — The  treatment  of  acute  and  chronic  hydro- 
cephalus by  tapping  has  not  yielded  encouraging  results.  The 
operation,  however,  is  justifiable,  and  if  performed  with  the  requi- 
site care,  devoid  of  danger.  In  infants  the  lateral  ventricle  has 
been  punctured  with  a  fine  trocar  through  the  open  anterior  fonta- 
nel. The  puncture  is  made  far  enough  from  the  median  line  to 
avoid  the  superior  longitudinal  sinus.  Not  more  than  two  ounces 
of  the  cerebrospinal  fluid  should  be  removed  at  one  time,  as  the 
evacuation  of  a  larger  quantity  is  likely  to  result  in  convulsions 
and  death.  Compression  of  the  skull  should  be  made  during  and 
after  the  operation. 

After  the  skull  has  become  ossified,  tapping  can  be  performed 
only  through  a  small  cranial  defect  made  with  the  chisel  or  trephine, 
but  under  such  conditions  the  operation  has  so  far  yielded  very 
unsatisfactory  results.  In  a  case  of  hydrops  of  the  lateral  ventricle 
in  a  young  man  who  came  under  my  observation,  the  lateral  ven- 
tricle was  tapped  through  an  opening  in  the  skull  made  with  the 
chisel,  and  two  ounces  of  cerebrospinal  fluid  were  removed  and  an 
ounce  of  a  weak  aqueous  solution  of  iodin  was  injected.  The 
operation  was  not  followed  by  any  untoward  symptoms,  and  re- 
sulted in  permanent  improvement. 

Lumbar  Puncture. — In  1891  Quincke  introduced  lumbar  punc- 
ture of  the  spinal  canal  as  a  therapeutic  measure  in  the  treatment 
of  serous  and  tubercular  meningitis  in  children.  This  procedure 
proved  very  useful  in  a  number  of  cases  of  cerebrospinal  menin- 
gitis during  the  Spanish-American  war.  The  patient  is  placed  on 
his  left  side,  and  the  lumbar  segment  of  the  spine  is  placed  in  a 
position  of  hyperextension.  With  a  fine  trocar  the  puncture  is 
made  below  the  arch  of  the  fourth  or  the  fifth  lumbar  vertebra, 
within  half  an  inch  of  the  median  line.  The  instrument  is  pushed 
obliquely  upward  and  inward  from  one  to  three  inches,  according 
to  the  age  of  the  patient  and  the  thickness  of  the  soft  tissues,  until 
the  subarachnoid  space  is  reached,  an  event  announced  by  the 
escape  of  cerebrospinal  fluid.  The  same  procedure  is  repeated  on 
the  reappearance  of  symj^toms  pointing  to  cerebrospinal  compres- 
sion. 

Paracentesis  Pericardii. — Puncture  of  the  pericardium  has  been 
made  a  legitimate  and  useful  surgical  resource  largely  through  the 


622 


EXPLORATORY  PUNCTURE. 


writings  of  Dr.  J.  B.  Roberts,  of  Philadelphia,  who  warmly  advo- 
cated the  operation  at  a  time  when  the  consensus  of  opinion  was 
opposed  to  it.  An  effusion  or  extravasation  in  the  pericardial  sac 
sufficient  in  quantity  to  compress  the  heart  is  a  source  of  imminent 
danger  to  hfe,  and  death  from  arrest  of  the  heart's  action  (peri- 
cardial tamponade,  E.  Rose)  can  often  be  averted  only  by  timely 
surgical  intervention.  The  evacuation  must  be  done  quite  slowly, 
through  the  cannula  of  a  very  fine  trocar  or  the  medium-sized  needle 
of  an  aspirator.  The  puncture  is  made  in  the  fourth  or  the  fifth 
intercostal  space,  about  an  inch  from  the  sternal  border. 

Thoracentesis. — Evacuation  of  fluid  from  the  cavity  of  the 
pleura  through  a  hollow  needle  or  a  small  trocar  is  an  operation 
known  as  thoracentesis.  Puncture  of  the  chest  and  evacuation 
of  its   fluid  contents  by  siphonage  or  aspiration   are  indicated  in 


C^ 


V 

/".'-••rv'i. 

M' 

*1 

!?'% 

•    ''v 

.•■\, 

-4- 
i 


^. 


A-' 


Fig.  417.- 


-Lumbar  puncture  of  the 
spinal  canal. 


Fig.  418. — Puncture  of  the  pericardium. 


hemothorax  after  the  hemorrhage  has  ceased  and  when  the  ex- 
travasation fails  to  disappear  by  absorption  in  due  course  of  time,  or 
as  soon  as  signs  and  symptoms  point  to  the  existence  of  infection 
of  the  contents  of  the  pleural  cavity.  Tapping  must  always  be 
postponed  until  bleeding  has  become  arrested,  as  the  extravasation 
itself  becomes  an  important  aid  in  effecting  hemostasis  by  pul- 
monary compression  and  the  formation  of  a  coagulum  at  the 
bleeding  point.  Unless  the  symptoms  are  very  urgent,  it  is  post- 
poned until  it  has  become  evident  that  removal  of  the  extravasated 
blood  by  absorption  is  no  longer  to  be  expected.  I  have  seen 
several  cases  of  gunshot  wounds  of  the  chest  in  which  the  entire 
pleural  cavity  was  filled  with  blood,  the  dullness  extending  to  the 
second  rib,  and  yet  disappearance  of  the  blood  by  absorption 
occurred  in  the  course  of  from  four  to  six  weeks. 


THORACENTESIS. 


623 


Upon  the  appearance  of  the  first  symptoms  of  infection,  tapping, 
under  strict  aseptic  precautions,  should  be  performed  without  delay. 
Early  tapping  and  evacuation  by  siphonage  are  necessary  in  the 
treatment  of  serous  pleuritis  with  copious  effusion.  Tapping  of  the 
chest,  if  properly  performed,  is  devoid  of  danger  and  at  once  relieves 
the  pulmonar\-  compression  and  embarrassed  action  of  the  heart, 
thus  placing  the  absorbents  in  a  condition  favorable  to  the  return 
of  their  physiologic  function.  Under  positive  intrathoracic  pres- 
sure the  stream  remains  continuous  unless  interrupted  by  blocking 
of  the  cannula  by  shreds  of  fibrin.  Should  this  occur,  the  lumen  is 
cleared  by  the  insertion  of  a  sterile  probe  or  wire  ;  should  this  fail, 
it  might  become  necessar\-  to  make  a  new  puncture.  With  the 
approach  of  negativ^e  intrathoracic  pressure  the  stream  diminishes 
in  size  and  force.  During  inspiration  it 
ceases  altogether,  when  the  fluid  in  the  basin 
is  drawn  into  the  tube  and  possibly  into  the 
cavity  of  the  chest,  to  be  expelled  during 
the  next  expiratory  movement  of  the  chest. 
Serous  pleuritis,  in  the  great  majority  of 
cases,  is  of  a  tubercular  nature,  and  if  the 
fluid  continues  to  accumulate  in  the  chest 
after  repeated  tappings,  much  is  gained  and 
nothing  risked  b}^  injecting  two  or  three 
drams  of  a  10  per  cent,  iodoform  glycerin 
emulsion  through  the  cannula  after  the  fluid 
has  been  withdrawn  by  siphonage.  If  the 
fluid  is  in  the  free  pleural  cavity,  the  punc- 
ture is  made  in  the  axillaiy  line,  usuall)- 
through  the  sixth  or  seventh  intercostal 
space. 

In  circumscribed  hydrothorax  the  center 
of  the  area  of  dullness  is  the  proper  place 
for  the  puncture.  The  arm  on  the  affected 
side  of  the  chest  should  be  raised  to  the  side 
of  the  head,  to  widen  the  intercostal  space. 

If  the  patient  is  a  child,  a  reliable  assistant  must  hold  it  securely 
until  the  operation  is  completed.  The  skin  is  anesthetized  by 
Schleich's  infiltration  method  or  b\'  the  freezing  spray.  The  left 
index-finger  is  used  as  a  guide  for  the  needle.  The  tip  of  the 
finger  is  pressed  as  deej)ly  as  possible  into  the  intercostal  space, 
when  the  needle  or  trocar  is  placed  along  the  radial  side  and 
pushed,  in  one  movement,  inward  and  slighth'  upward,  so  that  the 
puncture  will  correspond  with  the  direction  of  the  intercostal  space. 
Hy  f(;llowing  these  clirections  there  is  hardly  a  possil^iiit)'  of  striking 
a  rib  or  of  injuring  the  intercostal  nerve  or  vessels,  mishaps  that 
might  otherwi.se  occur. 

In   empyema   tapping  and   siphonage   constitute  an    important 
part  of  the  preparat(M-)'  treatment  of  the  siibsetjuent  radical  opera- 


Fig.  419. — Puncture  of  the 
pleural  cavity. 


624 


EXPLORATORY    PUNCTURE. 


tion.  Preliminary  partial  evacuation  of  the  pus  by  this  means  is 
conducive  to  pulmonary  expansion,  and  if  the  empyema  is  exten- 
sive, contributes  much  toward  diminishing  the  immediate  and  remote 
risks  of  the  subsequent  radical  operation.  If  the  pleural  infection 
is  mild  and  the  pus  thin  and  serous,  this  simple  and  safe  procedure 
occasionally  suffices  to  effect  a  cure,  more  especially  in  the  case  of 
children.  In  the  adult,  with  very  few  exceptions,  it  must  be  re- 
garded in  the  light  of  a  palliative  measure  and  as  a  valuable  pre- 
paratory procedure  to  incision  and  drainage. 

Paracentesis  Abdominis. — Tapping  of  the  abdomen  is  now 
resorted  to  almost  exclusively  for  the  evacuation  of  serum  in  cases 
of  ordinary  ascites  of  high  degree  or  tubercular  hydrops.  Punc- 
ture of  ovarian  cysts 
through  the  intact 
abdominal  wall,  for- 
merly frequently 
practised,  has,  for 
obvious  reasons, 
been  almost  entirely 
abandoned.  The 
large  trocar  has 
given  place  almost 
entirely  to  the  small 
hydrocele  trocar,  as 
it  is  necessary  to 
evacuate  the  fluid 
slowly  to  avoid 
dangerous  venous 
hyperemia  and  syn- 
cope. 

The  bladder 
should  be  empty  at 
the  time  the  punc- 
ture is  made.  The 
patient  is  placed  in 
a  semi-reclining  po- 
sition, and  the  abdomen  is  supported  by  passing  a  towel  or  broad 
bandage  twice  around  it,  crossed  in  the  region  of  the  umbilicus, 
traction  being  made  on  the  ends  by  an  assistant  standing  behind 
the  patient.  The  trocar  is  sterilized  by  boiling  in  soda  solution, 
and  the  skin  is  well  disinfected  in  the  usual  way.  The  puncture  is 
made  in  the  median  line,  half-way  between  the  pubes  and  umbilicus. 
Before  the  puncture  is  made  the  level  of  the  fluid  is  ascertained  by 
percussion,  the  tympanitic  space  above  indicating  the  location  of 
the  intestines  floating  on  the  fluid.  With  one  quick  movement  the 
mstrument  is  plunged  through  the  entire  thickness  of  the  abdominal 
wall,  the  sudden  cessation  of  resistance  announcing  that  the  point 
of  the  instrument  has  reached  its  destination.     As  the  stilet  is  with- 


Fig.  420. — Point  of  puncture  and  proper  position  of  patient 
in  tapping  the  abdomen  for  ascites. 


TAPPING    OF    JOINTS.  625 

drawn  the  fluid  escapes  through  the  cannula,  and  is  conveyed  into 
a  receptacle  by  a  piece  of  rubber  tubing  attached  to  the  end  of  the 
cannula.  The  fluid  should  be  withdrawn  very  slowly,  to  guard 
against  the  accidents  previously  referred  to.  As  the  abdomen  re- 
laxes the  bandage  is  drawn  sufficiently  tight  to  secure  the  necessary 
mechanical  pressure.  Should  the  heart's  action  at  any  time  show 
evidences  of  inefficiency,  stimulants  are  administered,  the  patient  is 
placed  in  the  dorsal  recumbent  position,  and  the  flow  of  fluid  is  in- 
terrupted until  reaction  is  established.  The  sudden  arrest  of  the 
stream  before  the  evacuation  is  completed  is  caused  by  closure  of 
the  cannula  by  the  omentum  or  intestines  or  a  wrong  direction  of 
the  cannula.  As  the  fluid  is  removed,  the  intestines  and  omentum 
descend,  when  the  cannula  should  be  directed  downward.  If  any 
of  the  abdominal  contents  occlude  the  cannula,  they  can  be  pushed 
backward  by  a  sterile  probe,  wire  loop,  or  catheter. 

After  the  completion  of  the  operation,  the  puncture  is  sealed 
with  iodoform  collodion,  and  the  abdomen  is  supported  by  a  well- 
fitting  abdominal  bandage  or  broad  flannel  roller.  Rest  for  a  day 
or  two  must  be  enforced.  Tapping  for  tubercular  ascites  should 
be  followed  by  injection  through  the  cannula  of  two  or  three  drams 
of  iodoform  glycerin  emulsion.  I  have  seen  two  cases  of  recovery 
from  this  affection  by  intraperitoneal  iodoformization  after  lapa- 
rotomy and  drainage  had  failed. 

Tapping  of  Joints. — Aseptic  tapping  of  joints  is  a  most  useful 
modern  therapeutic  resource,  as  it  relieves  pain  by  removing  tension, 
and  renders  the  diseased  joint  surfaces  accessible  to  direct  medication. 
Every  surgeon  knows  how  easy  it  is  to  infect  a  joint,  and  conse- 
quently resorts  to  the  most  scrupulous  aseptic  precautions  in  per- 
forming the  operation.  The  trocar  should  invariably  be  boiled  in 
soda  solution  before  the  tapping,  and  the  hands  of  the  surgeon  and 
the  point  of  puncture  should  be  disinfected  as  carefully  as  in  the 
preparation  for  a  major  operation.  The  small  trocar  that  accom- 
panies my  syringe  for  making  intra-articular  and  parenchymatous 
injections  is  very  well  adapted  for  puncturing  and  evacuating  any 
of  the  joints  that  are  ordinarily  subjected  to  this  method  of  treat- 
ment. 

To  prepare  the  .syringe  for  use,  the  rubber  cap  should  be  re- 
moved from  the  top  of  the  glass  cylinder,  which  is  then  filled  with 
the  fluid  to  be  injected,  after  which  the  cap  is  replaced.  Before 
making  the  puncture  with  the  needle  the  stop-cock  should  be 
opened  and  the  air  e.\'[)elled  from  the  rubber  tube  and  needle  by 
filling  them  with  the  fluid.  The  injection  should  be  made  slowly, 
by  steady  pressure  on  the  bulb  with  the  cylinder  in  a  vertical 
position. 

Simple  tapping  and  evacuation  of  the  joint  are  performed  in 
traumatic  and  [)athologic  hemarthrosis  when  the  extravasation  of 
blood  is  .sufficient  in  amount  to  cause  [)ainful  tension,  or  if  sponta- 
neous resorjjtion  fails  to  occur  within  the  expected  period  of  time. 
40 


626 


EXPLORATORY    PUNCTURE. 


After  the  evacuation  of  the  blood  the  joint  should  be  supported  by 
a  thick  cushion  of  cotton,  held  in  place  by  a  gauze  or  flannel  roller, 
and  immobilized.  The  same  procedure  is  applicable  in  the  treat- 
ment of  catarrhal  synovitis  with  copious  effusion.  In  gonorrheal 
synovitis  and  mild  forms  of  suppurative  synovitis  the  joint  should 
be  washed  out  with  a  2^  per  cent,  carbolic  acid  solution.  This 
can  be  done  with  the  injection  syringe  shown  in  the  illustration 
(Fig.  421).  The  joint  is  slightly  distended  with  the  solution,  which 
is  then  allowed  to  escape,  the  same  procedure  being  repeated  two 
or  three  times.      I  have  found  this  method  of  treatment  very  satis- 

factory  in  both 
forms  of  synovitis 
referred  to.  Should 
the  joint  again  be- 
come distended  in 
the  course  of  a  few 
days,  the  tapping 
and  intra-articular 
disinfection  are  re- 
peated. Elastic 
compression  of  the 
joint,  immobihza- 
tion,  and  elevation 
of  the  limb  con- 
stitute an  important 
part  of  the  after- 
treatment.  In  gon- 
orrheal synovitis  the 
internal  use  of  large 
doses  of  potassium 
iodid,  as  advised  by 
Professor  Schiiller, 
will  prove  useful. 

Intra-articular 
medication  after 
tapping  has  been 
found  most  satis- 
factory in  the  treatment  of  tubercular  abscesses  and  synovial  tuber- 
culosis. The  preparation  that  has  given  the  best  results  is  a 
sterilized  10  per  cent,  emulsion  of  iodoform  glycerin.  In  injecting 
a  tubercular  abscess  the  puncture  should  not  be  made  where  the 
abscess  wall  is  thinnest,  but  at  some  distance  from  the  most  promi- 
nent point  of  the  swelling,  so  that  the  puncture  will  be  made 
through  healthy  skin,  and  not  through  tissues  reduced  in  vitality 
from  the  long-continued  pressure  and  infection  from  beneath.  Be- 
fore the  puncture  is  made  the  skin  is  drawn  to  one  side,  so  that 
after  the  removal  of  the  cannula  the  puncture  in  the  deep  tissues  will 
be  subcutaneous.      If  the  joint  or  abscess  cavity  contain  broken- 


Fig.  421. — Senn's  injection  syringe. 


PUNCTIO    VESICA.  627 

down  tubercular  products  that  can  not  be  removed  through  the 
cannula,  the  joint  or  abscess  should  be  freely  incised,  the  interior 
scraped  and  rubbed  out  with  iodoform  gauze,  the  wound  sutured, 
and  then  the  injection  be  made,  a  plan  of  treatment  practised  with 
great  success  by  Billroth. 

Phelps  has  recently  recommended,  in  similar  cases,  the  appli- 
cation of  pure  carbolic  acid  to  the  diseased  surfaces,  followed  by 
alcohol.  He  speaks  in  the  highest  terms  of  the  curative  value  of 
this  treatment.  Iodoform  is  useless  m  any  form  after  the  joint  or 
abscess  cavity  lias  become  infected  witJi  pns-microbes.  Its  antibacillary 
action  is  limited  to  nncomplicated  tubercidar  processes. 

In  tapping  a  joint,  the  cardinal  rule  in  all  cases  should  be  to 
select  the  shortest  route  from  the  surface  into  the  different  joints, 
and  at  a  point  where  no  important  structures  will  come  into  the 
line  of  the  proposed  puncture.  The  shoulder-joint  is  punctured 
from  the  front ;  the  elbow-joint,  between  the  head  of  the  radius  and 
the  external  condyle  of  the  humerus  or  inner  border  of  the  olecranon 
process,  according  to  which  side  of  the  joint  is  most  extensively 
affected  ;  the  wrist-joint,  from  the  dorsal  surface.  The  best  place 
to  puncture  the  hip-joint  is  on  a  line  drawn  from  the  spine  of  the 
pubis  to  the  upper  margin  of  the  greater  trochanter  of  the  femur, 
and  at  a  point  corresponding  with  the  inner  margin  of  the  sartorius 
muscle.  The  knee-joint  is  most  accessible  at  a  point  corresponding 
with  the  outer  margin  of  the  patella,  near  its  upper  border.  The 
ankle-joint  is  punctured  on  either  the  tibial  or  fibular  side  from  the 
front,  care  being  taken  to  avoid  important  vessels  and  nerves. 

The  curative  value  of  intra-articular  injections  of  iodoform  gly- 
cerin emulsion  has  been  fully  established  by  a  large  clinical  experi- 
ence. As  before  stated,  the  best  results  are  obtained  in  cases  in 
which  the  tubercular  disease  remains  limited  to  the  soft  tissues  of 
the  joint.  The  dose  must  vary,  according  to  the  age  of  the  patient, 
from  two  to  four  drams.  As  some  persons  are  very  susceptible  to 
the  toxic  effect  of  iodoform,  it  is  advisable  to  begin  with  the  minimum 
dose,  and,  in  the  absence  of  such  idio.syncrasy,  increase  it  gradually 
in  repeating  the  injections.  The  interval  between  the  injections 
should  be  from  one  to  two  weeks.  The  most  favorable  indication 
of  the  curative  effect  of  the  iodoform  is  the  transformation  of  the  joint 
or  abscess  contents  into  a  viscid  fluid.  From  one  to  six  injections 
will  usually  suffice  in  ca.ses  susceptible  to  this  method  of  treatment. 
Ela.stic  compres.sion  of  the  joint  is  beneficial,  but  immobilization  can 
often  be  disi)enscd  with. 

Punctio  Vesicae. — Puncture  of  the  bladder  occasionally  becomes 
neces.sary  as  an  emergency  operation  in  the  treatment  of  retention 
of  urine  caused  by  rupture  of  the  urethra,  mechanical  obstruction 
from  enlargement  of  the  prostate,  or  stricture.  The  operation  is 
reserved  for  cases  in  which  the  surgeon  has  found  it  impo.ssible  to 
evacuate  the  bladder  by  catlieterization.  The  route  for  the  punc- 
ture now  invariably  selected  is  the  suprapubic.      For  good  reasons 


628 


EXPLORATORY    PUNCTURE. 


Fig.  422. — Bladder  distended 
by  retention  of  urine  (after  Fehl- 
eisen)  :  a,  Peritoneal  reflexion. 


puncturing  of  the  bladder  through  the  rectum  has  been  abandoned. 
As  the  bladder  is  always  much  distended  in  all  cases  that  justify 
evacuation  by  suprapubic  puncture,  ample  extraperitoneal  space  will 
be  found  between  the  symphysis  of  the  pubis  and  the  reflection  of 

the  parietal  peritoneum  above  the 
space  of  Retzius.  The  large  needle 
of  an  aspirator,  an  exploring  needle, 
or  a  small  straight  trocar  can  be  used 
as  a  useful  substitute  for  Fleurant's 
suprapubic  long  and  curved  trocar, 
made  for  this  special  purpose. 

The  suprapubic  region  is  shaved 
and  thoroughly  disinfected.  The 
puncture  is  made  in  the  median  line, 
directly  above  the  symphysis  pubis, 
and  the  instrument  is  pushed  back- 
ward and  slightly  downward  until 
resistance  ceases,  when  the  stilet  is 
withdrawn,  followed  by  the  escape  of 
urine  in  a  forcible  stream.  A  rubber 
tube  attached  to  the  cannula  will  fac- 
ilitate the  emptying  of  the  bladder. 
Fleujfant's  trocar  has  two  cannulas,  and  if  this  instrument  is  used, 
the  outer  cannula  is  fastened  in  place  with  strips  of  adhesive  plaster 
and  can  remain  for  the  necessaiy  length  of  time,  while  the  inner  can- 
nula is  frequently  removed,  cleansed,  and  reinserted.  The  greater 
the  distention  of  the  bladder,  the  slower  must  be  the  evacuation  of  its 
contents.  The  stream  is  interrupted  from  time  to  time  by  pressing 
the  finger-tip  against  the  end  of  the  cannula  or  by  compressing  the 
rubber  tube.  If  it  is  desired  to  maintain  suprapubic  drainage  for 
a  number  of  days  and  Fleurant's  catheter  is  not  at  hand,  a  small 
Nelaton  catheter  can  be  inserted  into  the  bladder  through  the  can- 
nula before  the  latter  is  withdrawn.  If  the  patient  is  within  easy 
reach  of  the  physician,  repeated  puncture  of  the  bladder  is  to  be 
preferred  to  the  establish- 
ment of  a  suprapubic  fis- 
tula. The  bladder  can  be 
punctured  once  or  twice  a 
day  for  a  number  of  days 
without  any  serious  con- 
sequences, provided  the 
punctures  are  made  under 
the  strictest  aseptic  pre- 
cautions. If,  from  the  nature  of  the  obstruction,  it  is  deemed  advis- 
able to  maintain  suprapubic  drainage  indefinitely  or  permanently, 
it  is  done  by  performing  cystostomy. 

With  the  pelvis  of  the  patient  elevated,  a  transverse  incision  is 
made  immediately  above  the  pubis,  three  inches  in  length,  down  to 


Fig.  423. — Senn's  sigmoid  catheter  for  suprapubic 
drainage  of  the  bladder. 


TAPPING    OF    HYDROCELE. 


629 


the  anterior  wall  of  the  bladder.  The  bladder  is  then  opened  trans- 
versely an  inch  and  a  half,  and  the  margins  of  the  visceral  v.ound 
sutured  to  the  skin.  My  sigmoid  catheter  will  be  found  very  useful 
as  a  permanent  drain  in  such  cases. 

Tapping  of  Hydrocele. — Tapping  of  a  hydrocele  is  performed 
as  either  a  palliative  operation  or  with  curati\e  intent,  if  followed 
by  the  injection  of  from  twent}'  to  thirty  drops  of  pure  carbolic 
acid,  tincture  of  iodin,  or  any  other  irritant.  The  puncture  is  made 
with  a  small  trocar.  The  exact  location  of  the  testicle  must  be  deter- 
viined  before  the  puncture  is  made.  The  swelling  is  grasped  with 
the  left  hand,  for  the  purpose  of  protecting  the  testicle  and  to  render 
the  skin  tense.  Visible  veins  are  avoided.  The  instrument  is 
thrust  into  the  sac  of  the  hydrocele,  and,  on  withdrawing  the  stilet, 
manual  compression  is  continued  until  the  fluid  is  evacuated.  If 
the  tapping  is  to  be  followed  by  an  injection,  the  cannula  must  not 
be  displaced,  so  as  to  insure  the  entrance  of  the  fluid  injected  into 


Fig.  424. — Tapping  of  hydrocele  (Esmarch  and  Kowalzig). 


the  sac  of  the  hydrocele,  as  injection  of  the  fluid  into  the  loose 
scrotal  connective  tissue  has  repeatedly  been  followed  by  necrosis 
and  other  serious  consequences.  The  puncture  is  sealed  with  iodo- 
form collodion,  and  the  relaxed  scrotum  is  properly  supported. 

Drainage  of  Suppurating  Joints. — The  indications  for  ampu- 
tation for  large  abscesses,  phlegmonous  inflammation,  and  sup- 
purating joints  have  become  very  few  since  surgeons  have  learned 
the  importance  of  free  drainage,  effective  antiseptic  irrigation,  con- 
tinuous or  at  short  intervals,  and  the  u.se  of  the  hot  moist  antiseptic 
dressing,  combined  with  immobilization  of  the  affected  limb  or  part. 
A  suppurating  joint,  as  an  isolated  affection  of  either  traumatic  or 
pathologic  origin,  seldom,  if  ever,  justifies  a  mutilating  operation  at 
the  pre.sent  time,  as  free  incision  and  efficient  drainage  usually  suf- 
fice in  protecting  the  life  of  the  patient  from  .sepsis,  and  generally 
succeed  in  restoring  the  limb  to  a  useful  position.  In  discussing 
the  treatment  of  suppurating  joints  by  incision  and  drainage  I  have 


630 


EXPLORATORY    PUNCTURE. 


excluded  all  tubercular  affections  of  joints  that  require  separate  con- 
sideration and  special  treatment.  The  average  practitioner  seldom 
drains  a  suppurating  joint  properly.  The  most  common  mistakes 
made  are  that  too  small  and  too  few  incisions  are  made  and  too 
small  drains  used.  No  joint  should  be  incised  until  the  presence 
of  pus  has  been  demonstrated  by  an  exploratory  puncture  or  by 
local  signs  and  general  symptoms  that  can  leave  no  doubt  as  to  the 
existence  of  intra-articular  suppuration.  The  diagnosis  being  estab- 
lished of  suppurative  synovitis  or  arthritis,  which  has  not  yielded 
or  does  not  come  within  the  range  of  successful  treatment  by  tap- 
ping and  intra-articular  antiseptic  irrigation,  the  following  treatment 
recommends  itself:  (i)  Free  incisions;  (2)  ample  drainage;  (3) 
antiseptic  irrigation  with  mild,  nontoxic,  yet  effective  antiseptic 
solutions  ;  (4)  moist  hot  antiseptic  compress  ;  (5)  immobilization 
of  the  limb  in  a  useful  position. 


Fig.  425. — Drainage  of  the  knee-joint. 

The  incisions  must  be  made  large  enough  to  furnish  space  for 
drains  of  ample  size,  and  at  points  where  drainage  is  most  required  ; 
they  should  be  sufficient  in  number  to  give  access  to  all  places 
where  retention  is  liable  to  occur.  The  knife  must  be  used  as 
sparingly  as  possible,  as  the  tissues  can  be  tunneled  more  safely 
with  locked  hemostatic  forceps.  Tubular  drains  should  be  em- 
ployed exclusively.  The  drains  should  seldom  be  smaller  than  the 
little  finger  in  draining  any  of  the  large  joints,  and  often  drains  the 
size  of  the  thumb  will  be  required.  Every  drain  must  be  supplied 
with  a  large  safety-pin.  For  continuous  intra-articular  irrigation 
Thiersch's  solution  or  a  saturated  solution  of  acetate  of  aluminum 
should  be  used.  The  compress  of  gauze  should  be  moistened  with 
one  of  these  solutions,  and  heat  and  moisture  be  retained  by  apply- 


DRAINAGE    OF    THE    KNEE-JOINT. 


631 


ing  over  it  an  impermeable  fabric,  such  as  gutta-percha,  mackintosh, 
oiled  silk,  or  rubber.  The  limb  should  be  invariably  immobilized 
in  a  useful  position  b\-  a  splint  that  will  permit  local  treatment  of 
the  joint  without  disturbing  it  ;  in  many  cases  it  will  be  a  source 
of  comfort  to  the  patient  to  combine  immobilization  with  suspen- 
sion. 

Drainage  of  the  Knee=joint. — The  knee-joint  can  be  efficiently 
drained  b\- making  an  incision,  at  least  an  inch  in  length,  just  above 
the  patella  on  each  side  of  the  joint,  and  placing  a  drain  the  size 
of  the  little  finger  transversely.  This  will  drain  the  upper  recess 
of  the  synovial  sac.  A  long  pair  of  hemostatic  forceps  are  then 
inserted  through  one  of  these  openings,  and  passed  obliquely 
through  the  joint  to  the  opposite  side  of  the  tendon  of  the  patella, 
when  the  point  of  the  instrument  is  pushed  through  the  tissues 
until  the  skin  is  raised  in  the  form  of  a  cone.      This  cone  is  then 


Fig.  426. — Drainage  of  the  ankle-joint. 


incised  at  its  base,  the  instrument  is  pushed  througii  the  opening, 
and  the  blades  arc  expanded.  With  a  drain  firmly  grasped,  the 
forceps  is  then  withdrawn.  Another  drain  is  inserted  in  a  similar 
manner  and  in  an  opposite  direction  from  the  other  incision. 

Drainage  of  the  Ankle=joint. — The  transverse  drain  is  placed 
underneath  the  extensor  muscles  and  the  tibialis  anticus  artery  and 
nerve  by  making  the  drainage  openings  immediately  in  front  of  the 
anterior  margin  of  tlie  malleoli.  The  anteroposterior  drain  is  in- 
serted by  passing  a  hemostatic  forceps  from  the  opening  on  the 
tibial  side  obliquely  across  the  joint  to  the  fibiikir  side  of  the 
Achilles  tendon,  where  the  counteropening  is  matle. 

The  shoulder- and  the  hip-joint  should  be  drained  in  an  antero- 
posterior direction.  Through  drainage  of  the  elbow-joint  can  be 
established  by  opening  the  radiohumeral  joint,  passing  the  forceps 


632 


ASEPTIC    CATHETERIZATION, 


across  the  joint,  and  making  the  counteropening  just  below  and  a 
httle  to  the  inner  side  and  in  front  of  the  internal  epicondyle,  so  as 
to  avoid  the  ulnar  nerve. 


CHAPTER  XIV. 

ASEPTIC  CATHETERIZATION, 

Successful  catheterization  premises  delicacy  of  touch,  the  em- 
ployment of  an  instrument  of  proper  construction,  a  practical 
knowledge  of  the  structure  of  the  urethra,  and  a  full  reliance  on 
aseptic  precautions.  There  is  perhaps  no  minor  surgical  procedure 
in  which  the  advantages  arising  from  skill  over  force  become  more 
apparent  than  in  the  use  of  the  catheter.  Skill,  patience,  and  per- 
severance often  succeed  in  overcoming  the  most  trying  obstacles  to 
catheterization  in  obstructive  affections  of  the  urethra,  while  unskilled 

attempts  to  pass  a 
catheter  through  a 
normal  urethra  have 
often  been  the  cause 
of  most  disastrous 
consequences.  Some 
men  acquire  the  nec- 
essary manual  dex- 
terity in  the  use  of  the 
catheter  very  readily, 
while  others  never 
become  proficient  in 
properly  handling  this 
instrument.  Every 
student  of  medicine 
should  be  thoroughly 
trained  in  the  technic 
of  catheterization  on 
the  cadaver  before  he 
attempts  to  use  the 
instrument  on  the  liv- 
urinary  fever,   urinary 


Fig.  427- — Schematic   representation  of  urethral   curve 
and  its  relation  to  the  symphysis  pubis  (Tillaux). 


ing  subject.      False  passages,   hemorrhage 

infiltrations,  urethritis,  and  septic  cystitis  are  some  of  the  complica 
tions  that  have  followed  reckless  catheterization.  Thousands  of 
lives  are  lost  annually  from  the  remote  consequences  of  infection 
following  the  use  of  the  catheter,  many  of  which  might  have  been 
saved  by  a  more  careful  handling  of  the  instrument,  combined  with 
the  most  pedantic  aseptic  precautions.  The  one  great  rule  that 
should  govern  the  surgeon  in  the  employment  of  the  catheter  is 
never  to  use  force. 


CATHETERS. 


^33 


Catheterization  has  become  much  safer  since  the  soft-rubber 
catheter  has  largely  taken  the  place  of  the  metallic  instrument. 
Traumatism  of  the  urethra,  so  frequently  inflicted  by  metallic 
catheters,  occurs  much  less  frequently  by  the  use  of  the  English 
catheters,  and  is  almost  entirely  avoided  by  the  employment  of 
the  soft-rubber  Nelaton  catheter.      The  French  catheter  is  the  ideal 


Fig.  428. — Male  urethra  (wax  cast,  after  Home). 


instrument  in  all  cases  in  which  the  urethra  is  large  enough  to  admit 
its  passage.  The  prostatic  catheter  (Fig.  434)  with  a  short,  sharply 
bent  beak  will  be  found  most  useful  in  catheterization  of  patients 
suffering  from  enlargement  of  the  prostatic  gland.  Kelly's  glass 
catheter  should  be  used  exclusively  in  females,  as  it  is  cheap  and 
can  easily  be  disinfected  and  kept  in  an  aseptic  condition. 

The  most  common  mistake  made  in  introducing  the  inflexible 
catheter  is  in  following  the  floor  instead  of  the  roof  of  the  urethra 
after  the  point  of  the  instrument  has  passed  the  pubic  arch.  If  a 
metal  catheter  is  used,  an  instrument  with  a  proper  curve  must  be 
selected.  In  passing  the  catheter  as  far  as  the  pubic  arch  the  distal 
end  of  the  instru- 
ment should  not 
be  raised  more 
than  45  degrees 
from  the  surface 
of  the  abdomen  ; 
the  half  circle 
which  it  must 
make  before  the 
bladder  is  reached  ^'K-  429- — French  soft-rubber  elastic  catheter. 

is     then     rapidly 

completed,  a  manc^uvcr  that  keeps  the  jicMiit  of  the  in.strumcnt  in 
contact  with  tiie  urethral  roof,  avoiding,  in  this  manner,  the 
prostate. 

Wounds  and  abrasions  made  with  the  catheter  serve  as  entrance 
gates  to  the  [)athogcnic  microbes,  and  for  this  reason,  if  for  no 
other,  must  carefully  be  avoided.  77ie  norinal  bladder  is  difficult  to 
infect ;  the  paralyzed  and  diseased  bladder,  on  the  other  hand,  is  very 
susceptible  to  infection.      In   the  study  f;f  the  suscei)tibility  of  the 


634 


ASEPTIC    CATHETERIZATION, 


bladder  to  infection  it  is  important  to  obtain  a  clear  conception  of  the 
function  of  its  mucous  lining.  The  epithelial  lining  of  this  organ  is 
not,  properly  speaking,  a  mucous  membrane,  as  it  is  not  supplied 

with  glandular  appendages,  and  in  a  nor- 
mal state  secretes  no  mucus.  It  is  the 
reservoir  for  an  excretion  and  not  for  a 
secretion.  For  this,  if  for  no  other,  rea- 
son, we  should,  a  priori,  question  its 
ability  to  absorb  medicinal  and  other 
substances.  The  mucosa  of  the  bladder 
contains  no  lymphatics  ;  it  lacks,  there- 
fore, all  the  physiologic  elements  neces- 
sary for  absorption.  Gerota,  in  the  ex- 
amination of  more  than  sixty  bladders, 
could  not  demonstrate,  either  macroscop- 
ically  or  microscopically,  the  presence 
of  lymphatics  belonging  to  the  mucous 
membrane.  The  few  vessels  found  in 
the  submucosa  of  the  vesical  neck  were 
identified  in  the  lymphatics  of  the  urethra, 
which  extend  for  a  short  distance  into  the 
neck  of  the  bladder,  but  soon  enter  the 
muscular  coat.  That  the  normal  mucous 
membrane  of  the  bladder  is  not  an  ab- 
sorbing surface  has  been  demonstrated 
by  the  clinical  observations  of  Civiale  and 
many  other  surgeons  and  the  experimental 
work  of  many  investigators,  among  them 
Kuss,  Susine,  Alpay,  Ailing,  Lewin  and 
Goldschmidt,  Cazeneuve,  and  Livon.  Hot- 
tinger's  experiments  seem  to  prove  that 
enormous  quantities  of  poison  must  be 
introduced  into  the  bladder  of  animals  to 
produce  death.  Death  in  such  cases  he 
attributes  to  a  process  of  diffusion  rather 
than  to  absorption. 

Lewin  and  Goldschmidt  made  many 
experiments  on  animals,  and  came  to  the 
conclusion  that  the  healthy  mucous  mem- 
brane of  the  bladder  is  impermeable  to 
toxic  substances,  and,  when  absorption 
does  take  place,  it  is  from  the  prostatic 
portion.  Their  experiments  Avere  made 
by  ligating  the  neck  of  the  bladder  and 
injecting  the  solution  directly  into  the  bladder  through  an  abdom- 
inal incision. 

Although  Pasteur  ascertained,  in  i860,  that  the   decomposition 
of  the  urine   outside  of  the  body  and  in  the  inflamed   bladder   is 


Fig.  430.  —  Comparative 
width  and  length  of  the  differ- 
ent anatomic  parts  of  the 
urethral  canal :  a.  Fossa  na- 
vicularis ;  b,  cavernous  por- 
tion ;  c,  bulbar  enlargement ; 
d,  membranous  portion ;  e, 
prostatic  portion  (Finger). 


CATHETERS. 


635 


Fig.  431. — Ulive-tip  elastic  web  catheter. 


Fig.  432. — Cylindric  elastic  web  catheter. 


Fig.  433. — Conic  elastic  web  catheter. 


Fig.  434. — Mercier's  single-elbow  prostatic  catheter. 


Fig.  435. — Large-curve  prostatic  web  catheter. 


Fig.  436. — Ordinary  male  metal  catheter. 


Fig.  437. — Metal  prostatic  catheter. 


636 


ASEPTIC    CATHETERIZATION. 


caused  by  the  action  of  micro-organisms,  our  knowledge  of  the 
putrefactive  changes  of  urine  remains  imperfect  at  the  present  time. 
He  described  the  bacteriologic  cause  of  urine  decomposition,  the 
microbe  that  he  so  constantly  found,  as  ''une  des  torulacee  en  chap- 
el ets  des  ires petits  grains." 

Among  the  predisposing  causes  of  cystitis  must  be  mentioned 
retention  of  urine,  unrest  of  the  bladder,  abnormal  urine,  tumors, 


Fig.  438. — Jointed  male  and  female  catheter. 


calculus  and  foreign  bodies,  pressure,  exposure  to  cold,  venous 
stasis,  mechanical  obstruction,  and  trauma.  It  is  in  the  presence 
of  such  predisposing  causes  that  catheterization  is  attended  by 
increased  risk  of  infection. 

From  a  practical  standpoint  the  exciting  causes  are  such  as  are 
instrumental  in  introducing  into  the  bladder  pathogenic  microbes  in 
sufficient  number  and  virulence  to  exert  their  specific  pathogenic 
effect  on  a  soil  prepared  for  their  reception  and  reproduction,  and 
among  these  careless  catheterization  figures  as  the  most  frequent. 
Every  surgeon  is  familiar  with  the  frequency  with  which  the  passage 
of  instruments  into  the  bladder  is  followed  by  cystitis,  particularly 
when  the  urethra  is  the  seat  of  inflammation  and  in  case  catheter- 
ization is  performed  for  retention  of 
urine  under  any  but  the  strictest 
aseptic  precautions. 

By  continuity  of  surface  a  sup- 
purative inflammation  of  the  urethra 
may  extend  to  the  bladder  without 
instrumental  intervention.  Complete 
sterilization  of  catheter  and  hands 
does  not  always  succeed  in  depriving 
catheterization  of  the  danger  of  blad- 
der infection.  Pathogenic  microbes  are  almost  constantly  found  in 
the  normal  urethra  of  healthy  persons.  Lustgarten  and  Mannaberg 
made  a  bacteriologic  examination  of  the  urethrse  of  eight  healthy 
men,  and  found  ten  different  kinds  of  micro-organisms,  among  them 
a  number  that  are  known  to  produce  cystitis.  The  meatus  urethrae 
is  a  favorite  lodging-place  for  microbes.  If  the  meatus  is  not  disin- 
fected before  insertion  of  the  catheter,  microbes  may  be  carried  with 


Fig.  439. — Proper  curve  (Van  Buren 
and  Keyes). 


TECHNIC. 


637 


the  instrument  into  the  bladder  sufficient  in  number  and  virulence 
to  provoke  a  cystitis,  provided  they  are  brought  in  contact  with  a 


Fig.  440. — Faulty  curves  (Van  Buren  and  Keyes). 

soil  prepared  for  their   reception   and   growth  by  an   injury   or  by 
antecedent  lesions. 

During  a  visit,  a  few  years  ago,  to  the  obstetric  wards  of  Pro- 
fessor von  Winckel,  I  was  informed  that,  for  some  time,  quite  a  large 
number  of  recently  delivered   women   had    suffered   from  cystitis. 


Fig.  441. — Technic  of  catheterization  (Esmarch  and  Kowalzig).  Manner  of 
holding  penis  and  catheter,  and  jjosition  of  the  same  on  inserting  it  into  the  meatus  ; 
b,  position  of  catheter  on  ])assing  prostatic  portion  of  urethra  ;  c,  catheter  in  the  bladder. 

The  strictest  anti.scptic  precautions  were  practised  in  sterihzing 
in.struments  and  hands,  but  the  prevalence  of  this  puerperal  compli- 
cation continued  until  the  professor  introduced  an  additional  pre- 
cautionary measure  in  all  cases  rcfiuiring  the  use  of  the  catheter — 
namely,   disinfection   of  the    meatus   with    a   solution    of    mercuric 


538  ASEPTIC    CATHETERIZATION. 

bichlorid.  From  that  time  on  cystitis  from  this  cause  disappeared 
from  the  lying-in  wards. 

I  have  seen  numerous  cases  of  cystitis  followmg  the  use  of  the 
catheter  after  abdominal  operations,  but  since  I  instructed  the 
nurses  to  precede  the  insertion  of  the  catheter  by  disinfection  of  the 
meatus,  such  cases  have  disappeared.  Secondary  gonorrheal  cys- 
titis following  a  specific  urethritis,  although  a  rare  complication, 
does  occur,  but  is  more  prone  to  follow  a  mixed  infection  of  the 
urethra. 

In  view  of  the  facts  that  it  is  difficult  to  disinfect  the  meatus 
completely,  and  that  pathogenic  bacteria  always  inhabit  the  urethra, 
it  is  necessary  not  only  to  sterilize  hands  and  instruments,  but  to 
employ,  at  the  same  time,  antiseptic  precautions  for  the  purpose  of 
protecting  the  bladder  against  infection.  The  English  hard-rubber 
catheter,  covered  with  a  coat  of  varnish,  can  not  be  sterilized  by 
boiling  without  ruining  the  instrument,  and  chemic  disinfection 
can  not  be  relied  upon  in  rendering  it  aseptic  ;  consequently  it  is 
seldom  employed  at  the  present  time.  The  soft-rubber  catheter 
can  be  sterilized  by  boiling  in  soda  solution,  and  for  daily  practice 
should  be  placed  in  an  aseptic  glass  or  metallic  tube,  corresponding 
in  length  to  the  instruments,  and  carried  in  the  emergency  bag  and 


Fig.  442. — Papier-miche  catheter  case. 

not  in  the  instrument  case.  The  tube  should  be  large  enough  to 
contain  at  least  instruments  of  four  sizes.  The  metallic  catheter 
can  be  sterilized  by  boiling  before  using  it.  Thorough  washing 
and  rinsing  of  the  lumen  of  the  instrument  in  hot  water  after 
using  prepare  it  properly  for  the  subsequent  disinfection  by  boiling 
or  immersion  in  a  strong  antiseptic  solution. 

Disinfection  of  the  meatus  with  a  i  :  1000  solution  of  bichlorid 
of  mercury,  a  5  per  cent,  solution  of  carbolic  acid,  or  absolute 
alcohol  should  always  precede  the  insertion  of  the  instrument. 
The  hands  must  be  disinfected  with  the  same  care  as  is  used  in  the 
preparation  for  an  operation.  The  glans  penis  should  be  wrapped 
in  gauze,  thus  affording  a  firmer  hold  for  the  left  hand,  and  serving 
as  an  additional  safeguard  in  preventing  contamination  of  the  dis- 
infected meatus  and  the  instrument.  It  is  customary  to  lubricate 
the  instrument  with  some  kind  of  fat  or  oil,  to  facilitate  its  inser- 
tion. Rancid  fat,  butter,  or  unsterilized  vaselin  are  frequently  used 
for  this  purpose,  and  there  can  be  but  little  doubt  that  infection  has 
often  occurred  from  this  source.  Fatty  material  as  a  coating  for 
the  catheter  is  of  advantage  not  only  in  facilitating  the  insertion  of 
the  instrument,  but  also  in  furnishing  for  the  urethral  microbes  a 
mantle  of  an  indifferent  substance,  and,  in  doing  so,  preventing 
their  direct  contact  with  the   mucous   membrane   of  the  bladder. 


TECHNIC.  639 

TJiis  coating  for  the  catheter  and  mantle  for  the  microbes  should  be 
not  only  aseptic,  but  also  antiseptic.  The  fatty  material  must  be  ster- 
ilized and  made  antiseptic  by  incorporating  ivith  it  a  nonirritating  but 
efficient  a?itiseptic.  The  best  preparation  to  fulfil  the  indications  for 
aseptic  catheterization  is  sterilized  vaselin,  with  the  addition  of  2^ 
per  cent,  carbolic  acid  or  i  per  cent,  of  formic  aldehyd.  This 
should  be  kept  in  a  collapsible  metallic  tube,  and  be  carried  in  every 
emergency  bag.  Belfield  recommends  a  5  per  cent,  solution  of 
boric  acid  in  glycerin.  After  the  catheter  has  been  used,  the  coat- 
ing of  fat  must  be  removed  b}-  thorough  scrubbing  with  hot  water 
and  soap  preparatory  to  disinfection. 

The  microbes  enveloped  by  an  antiseptic  mantle  of  fat,  even  if 
they  reach  the  bladder,  will  escape  with  the  urine,  and  such  as  may 
remain  are  rendered  more  or  less  harmless  by  the  inhibitory  action 
of  the  antiseptic.  The  material  for  the  lubrication  of  the  instrument, 
properly  selected  and  prepared,  thus  becomes  an  important  pre- 
ventive against,  instead  of  a  fruitful  source  of,  infection,  as  has  been 
only  too  often  the  case  in  the  past.  The  most  pedantic  care  in  pre- 
venting infection  becomes  of  the  utmost  importance  in  the  treatment 
of  cases  requiring  systematic  catheterization  for  a  long  time,  as  is 
the  case  in  paraplegia  caused  by  injury  or  disease  of  the  spine  and 
in  prostatic  obstruction. 

In  private  practice  catheterization  must,  of  necessity,  often  be 
intrusted  to  unskilled  hands.  Under  such  circumstances  the  surgeon 
must  give  explicit  instructions  in  the  use  of  the  instrument,  and  the 
one  who  takes  his  place  during  his  absence  must  acquire  the  requi- 
site knowledge  and  skill  under  his  personal  supervision.  The  Ne- 
laton  soft-rubber  catheter  is  the  only  safe  instrument  in  the  Jiands  of  a 
laypian.  The  method  of  sterilization  of  the  instrument  and  its 
proper  care  and  use  must  be  fully  explained.  A  number  of  catheters 
must  be  kept  on  hand  ready  for  use.  It  must  not  be  forgotten  that, 
as  a  rule,  a  large  catheter  pas.ses  through  the  urethra  more  readily 
than  a  small  one  ;  this  feet  is  often  forgotten  b}^  the  general  prac- 
titioner. The  instruments  should  be  kept  in  a  5  per  cent,  solution 
of  carbolic  acid  and  suspended  in  a  glass  jar  with  a  wide  mouth  and 
glass  stopper.  The  glass  stopper  is  covered  with  a  piece  of  aseptic 
gauze  to  which  tlie  catheters  are  fastened  with  small  safety-pins. 
The  fluid  should  be  changed  every  few  da)'s,  and  the  catheter,  after 
use,  should  be  thoroughly  cleansed  with  hot  water  and  soap  before 
it  is  immensed  in  the  .solution.  Before  the  instrument  is  inserted  it 
is  rinsed  in  warm  boiled  water  to  free  it  from  the  carbolic  acid, 
wiped  dry  vvitli  an  asejjtic  towel,  and  lubricated  with  the  antiseptic 
vaselin  pomade  squeezed  from  tin;  collapsiljle  tube.  Thorough  dis- 
infection of  the  hands  before  hantlling  and  in.serting  the  catheter 
mu.st  be  insi.stcd  upon,  as  well  as  the  preliminary  di.sinfection  of  the 
meatus.  The  patient  him.self  will  often  be  found  the  one  most  com- 
petent and  reliable  to  carry  out  the  directions  given  by  the  surgeon. 
Trained  nurses  may  usually  be  relied  on  for  this  service. 


CHAPTER  XV. 


EMERGENCY  OPERATIONS  ON  THE  AIR-PASSAGES* 

Intubation  of  the  Larynx. — The  mechanical  treatment  of  in- 
flammatory stenosis  of  the  larynx  by  intubation  was  conceived  and 
brought  to  its  present  state  of  perfection  by  the  late  Dr.  O'Dwyer, 
of  New  York.  As  a  substitute  for  tracheotomy  it  has  ^nelded  the 
most  gratifying  results  in  children  less  than  five  years  of  age.  Suc- 
cessful intubation  requires  a  full  set  of  instruments,  much  practice 
in  the  technic  of  the  operation,  and  constant  watchfulness  during 
the  entire  after-treatment.  No  one  should  attempt  intubation  with- 
out having  received  full  instruction  and  without  having  acquired  the 
necessary  manual  dexterity  in  inserting  and  extracting  the  tube 
quickly  and  safely.  As  a  substitute  for  tracheotomy  it  has  become 
a  favorite  procedure  in  this  country,  more  so  than  in  any  other. 

This  is,  perhaps,  due 
to  the  fact  that  on  the 
continent  of  Europe 
children  suffering 
f  r  o  m  inflammatory 
stenosis  of  the  larynx 
are  generally  taken  to 
the  hospitals,  where 
the  treatment  after 
tracheotomy  is  placed 
in  the  hands  of  skilled 
assistants  and  experi- 
enced nurses,  thus 
insuring  better  results 
after  this  operation 
than  can  be  obtained  in  private  homes,  even  under  the  most  favor- 
able circumstances.  In  this  country  the  treatment  of  such  cases  is 
usually  conducted  at  the  homes  of  the  patients,  where  intubation  in 
children  under  six  years  of  age  has  certainly  yielded  much  better 
results  than  tracheotomy.  Every  general  practitioner  should  make 
himself  fully  conversant  with  the  technic  of  intubation,  more  par- 
ticularly if  he  lives  in  a  locality  where  he  can  not  avail  himself  of 
the  services  of  an  expert.  Medical  colleges  and  post-graduate, 
schools  should  make  ample  provision  for  practical  instruction  in 
mtubation,  to  prepare  the  students  and  practitioners  properly  for 
this  important  part  of  their  calling. 

Intubation  is  a  surgical  precedure  that  requires  for  its  successful 
performance  an  intimate  knowledge  of  the  anatomy  of  the  seat  of 

640 


Fig.  443- — O'Dwyer's  intubation  tubes. 


INTUBATION  OF  THE  LARYNX. 


641 


the  disease,  and  delicate  manipulation  for  the  insertion  and  re- 
moval of  the  tube.  The  directions  for  intubation  given  below  are 
taken  from  the  third  edition  of  "  Diseases  of  the  Chest,  Throat, 
and  Nasal  Cavities,  etc.,"  by  Professor  E.  F.  Ingals,  who  has  had  a 
very  extensive  experience  in  this  department  of  special  work. 

"  The  tube  must  be  selected  with  special  reference  to  the  age  of 
the  child.     A  strong  thread,  about  three  feet  in  length,  is  passed 


Fig.  444. — O'Dwyer's  introducer. 


Fig.  445. — O'Dwyer's  extractor 


Fig.  446. — Waxhain's  mouth-gag. 


through  the  eyelet  in  its  head,  and  the  ends  are  tied  together. 
The  applicator  is  then  screwed  into  the  obturator  and  this  pa.s.sed 
through  the  tube,  ready  for  the  operation.  The  short  side  of  the 
tube  should  be  |)laccd  toward  the  handle  of  the  in.strumcnt.  so  that 
when  introduced  into  the  larynx,  it  will  conform  to  the  position  of 
the  epiglottis. 
41 


642  EMERGENCY    OPERATIONS    ON    THE    AIR-PASSAGES. 

"The  child,  wrapped  in  a  blanket  or  sheet,  which  is  pinned 
closely  about  the  neck  so  that  its  arms  are  pinioned,  should  be 
held  in  the  arms  of  the  nurse,  with  its  head  against  the  nurse's  left 
shoulder.  The  gag  is  then  inserted  between  the  teeth  upon  the 
left  side,  and  intrusted  to  the  assistant  who  is  to  hold  the  head. 
The  forefinger  of  the  operator's  left  hand  should  be  oiled  or 
smeared  with  vaselin,  to  prevent  inoculation  through  any  abrasions 
upon  the  surface  in  case  the  disease  should  prove  to  be  diphtheria. 
A  broad  metallic  ring  or  a  rubber  finger-cot,  the  head  of  which  has 
been  cut  off,  should  be  slipped  over  the  finger,  to  prevent  the 
patient  from  biting  it  in  case  the  gag  should  become  displaced  ;  or, 
in  the  absence  of  these,  the  finger  may  be  wound  with  a  strip  of 
cloth,  which  will  answer  the  purpose  fairly  well.  The  tube,  with 
the  applicator,  having  been  dipped  into  warm  water  to  bring  it  to 
blood-heat,  is  ready  for  introduction.  The  child's  head  being 
thrown  slightly  backward  and  held  firmly  by  the  assistant,  the 
operator  introduces  the  forefinger  of  the  left  hand  over  the  base  of 
the  tongue,  down  behind  the  epiglottis,  until  he  feels  the  arytenoid 
cartilage,  upon  the  upper  edge  of  which  the  finger  rests.  The 
tube  is  now  guided  down  along  the  palmar  surface  of  the  finger 
until  it  reaches  the  larynx,  when,  the  handle  of  the  applicator  being 
elevated  so  as  to  turn  the  end  of  the  tube  further  forward,  it  is 
passed  into  the  glottis  and  crowded  downward  about  half  an  inch. 
At  the  same  time  the  end  of  the  finger  that  is  resting  on  the  aryte- 
noid is  brought  upward  and  placed  upon  the  upper  end  of  the 
tube,  which  is  forced  downward  so  far  as  possible.  The  slide  upon 
the  applicator  is  then  shoved  forward,  the  obturator  disengaged,  and 
the  applicator  removed,  while  with  the  finger  of  the  left  hand  the 
operator  crowds  the  head  of  the  tube  fairly  into  the  vestibule  of 
the  larynx.  Not  more  than  ten  seconds  should  be  consumed  in 
this  operation  ;  if  in  this  time  the  operator  does  not  succeed  in 
introducing  the  tube,  it  is  better  to  withdraw  it  and  allow  the  child 
to  breathe  for  a  moment  before  making  another  effort. 

"  As  the  tube  is  introduced  the  child  generally  coughs,  and  the 
respiration  has  a  peculiar  tubular  sound,  which  indicates  that  the 
tube  has  been  properly  placed  in  the  air-passage.  If  this  sound  is 
not  heard,  the  operator  should  feel  again  for  the  tube,  to  ascertain 
whether  or  not  it  has  been  passed  into  the  esophagus  instead  of  into 
the  larynx.  If  not  in  proper  position,  it  must  be  withdrawn  by  the 
string  and  another  effort  be  made  to  introduce  it.  If  in  correct 
position,  it  should  be  allowed  to  remain  with  the  string  attached  for 
a  few  minutes,  until  respiration  becomes  thoroughly  established  and 
the  child  has  finished  coughing.  One  of  the  threads  should  then 
be  cut  near  the  lips,  the  operator's  forefinger  being  carried  down  to 
the  head  of  the  tube  to  hold  it  in  position,  and  the  string  withdrawn. 
The  tube  is  left  in  the  larynx,  where  it  should  remain  for  from  two 
to  six  days,  unless  it  should  become  partially  stopped  by  dried 
mucus,  indicated  by  difficult  breathing,  or  unless  subsidence  of  the 


LARYNGOFISSURE.  643 

symptoms  leads  one  to  believe  that  the  swelling  has  subsided  and 
the  false  membrane  disappeared.  In  many  cases  the  tube  will  be 
coughed  out  as  soon  as  the  necessity  for  its  further  use  ceases. 
When  it  becomes  desirable  to  remove  it,  the  child  is  placed  in  the 
same  position  as  for  its  introduction,  and  with  the  index-finger  of 
the  left  hand  the  operator  guides  the  extractor  down  to  the  larynx, 
when  it  may  be  felt  to  strike  against  the  end  of  the  tube.  It  is  then 
moved  about  gently,  no  force  being  used,  until  it  drops  into  the 
opening  of  the  tube  ;  the  blades  are  then  separated  and  firmly  held 
while  the  instrument  and  the  tube  are  being  withdrawn.  Special 
care  should  be  observed  not  to  relax  the  pressure  just  as  the  tube 
is  being  turned  out  of  the  pharynx,  for  if  this  is  done,  the  instru- 
ment will  slip,  and  the  tube  may  either  fall  back  into  the  larynx 
or  be  swallowed.  It  is  well  to  have  a  pair  of  forceps  at  hand  for 
the  purpose  of  seizing  the  tube  in  case  the  instrument  should  slip  at 
this  stage  of  its  withdrawal.  Special  precaution  should  be  taken 
that  no  pressure  is  made  upon  the  head  of  the  tube  in  attempting 
to  introduce  the  extractor,  for  the  tube  might  possibly  be  pushed 
below  the  vocal  cords,  an  accident  that  has  happened  in  a  few 
cases." 

Success  in  the  operation  of  intubation,  as  in  tracheotomy,  is  the 
well-earned  reward  of  constant  watchfulness  during  the  after-treat- 
ment. One  of  the  dangers  incident  to  intubation  in  puny  children 
is  the  entrance  of  food  or  drink  into  the  air-passages  if  taken  when 
the  child  is  in  a  sitting  position.  To  avoid  this  danger,  Frank 
Cary,  of  Chicago,  recommended  the  placing  of  the  head  of  the 
child  in  Rose's  position, — that  is,  placing  the  head  much  lower 
than  the  body, — and  feeding  it  from  a  nursing-bottle  or  through  a 
tube.  "  Soft  solids  may  be  given  with  the  child  in  any  position,  and 
some  children  will  speedily  learn  to  swallow  even  fluids  in  the 
erect  position  ;  but  the  friends  must  be  cautioned  not  to  try  the 
experiment." 

Occasionally,  on  introducing  the  tube,  some  portion  of  the 
false  membrane  is  forced  bclo\y  it  into  the  trachea,  and  suffocation 
becomes  imminent.  If  this  occurs,  the  tube  should  be  at  once 
withdrawn,  when  it  usually  brings  the  membrane  with  it,  or  the 
latter  will  speedily  be  coughed  out.  If  this  should  not  occur, 
tracheotomy  should  be  done  at  once.  Because  of  the  liability  of 
this  accident,  the  operator  should  always  have  his  tracheotomy  in- 
struments at  hand  when  performing  intubation. 

Laryngofissure. — Incision  of  the  larynx  through  the  anterior 
median  line  is  technically  called  laryngofi.ssure.  This  operation  is 
a[)j)licable  for  the  removal  of  benign  growths  and  foreign  bodies 
lodged  in  the  interior  of  the  larynx.  The  operation  is  not  difficult, 
and  affords  free  access  to  the  interior  of  the  larynx.  If  the  incision 
is  made  as  it  should  be,  through  tiie  median  line,  the  only  blood- 
vessel of  any  account  that  falls  into  the  line  of  the  incision  is  the 
cricothyroid  artery;   this  can   readily   be  caught   with    hemostatic 


644 


EMERGENCY    OPERATIONS    ON    THE    AIR-PASSAGES. 


forceps,  and  tied  by  either  direct  or  indirect  ligation.  Unless  the 
patient  is  very  young,  the  operation  should  invariably  be  performed 
under  local  anesthesia  by  Schleich's  infiltration  method,  as  the  co- 
operation of  the  patient  in  clearing  the  larynx  of  blood  after  the 
deep  incision  has  been  made  renders  a  preliminary  tracheotomy 
superfluous. 

The  patient  is  placed  in  the  supine  position,  with  the  head  well 
extended  and  the  shoulders  and  neck  resting  upon  a  firm  cylindric 
cushion.  An  assistant  immobilizes  the  head  until  the  operation  is 
completed.  With  the  head  well  thrown  back,  the  larynx  and 
upper  part  of  the  trachea  become  prominent  and  easy  of  access. 
An  incision  is  made  through  the  skin  and  superficial  fascia  from 
the  upper  border  of  the  thyroid  cartilage  to  the  first  tracheal  ring. 
The  thyrohyal  membrane  is  next  divided  along  the  upper  border 
of  the  thyroid  cartilage  sufficiently  to  permit  the  entrance  of  the 
point  of  the  scalpel  with  which  the  thyroid  cartilage,  the  cricothy- 
roid membrane,  and 
the  cricoid  cartilages 
are  then  divided  with 
one  sweep  of  the 
knife.  If  more  room 
is  required,  the  first 
tracheal  ring  is  also 
divided.  The  crico- 
thyroid artery  is  se- 
cured as  soon  as  cut, 
and  it  is  about  the 
only  vessel  that  re- 
quires attention  dur- 
ing the  entire  opera- 
tion, provided  the  in- 
cision is  made  exactly  in  the  median  line.  With  sharp  tenacula  or 
retractors  the  margins  of  the  wound  are  retracted  sufficiently  to 
expose  the  interior  of  the  larynx  freely  for  the  detection  and  extrac- 
tion of  foreign  bodies,  or  for  the  radical  removal  of  tubercular  pro- 
ducts or  benign  growths.  In  persons  advanced  in  years  it  may 
become  necessary  to  substitute  the  bone-cutting  forceps  for  the  knife 
in  incising  the  larynx.  In  operations  for  intralaryngeal  tubercular 
affections  the  use  of  the  sharp  curet  is  followed  by  the  vigorous  use 
of  the  Paquelin  cautery  to  eradicate  the  disease  more  completely 
and  to  arrest  the  hemorrhage.  At  the  completion  of  the  operation 
the  laryngeal  wound  is  closed  by  a  number  of  catgut  sutures,  which 
are  made  to  include  the  perichondrium  and  the  overlying  connective 
tissue.  The  external  incision  is  then  closed  throughout  by  suturing 
in  the  usual  manner,  without  making  any  provision  for  drainage,  as 
primary  healing  of  the  wound  may  confidently  be  expected. 

Tracheotomy. — Tracheotomy  signifies  opening  of  the  trachea 
at  any  point  between  the  cricoid  cartilage  and  the  sternum.      This 


Fig.  447. 


-Position  of  patient  for  laryngotomy  and 
tracheotomy. 


TRACK  EOTOMV. 


645 


operation  is  usually  performed  as  a  life-saving  procedure  in  obstruc- 
tive lesions  of  the  laiynx  in  cases  in  which  intubation  is  impracti- 
cable or  has  failed  to  procure  the  expected  relief.  Occasionally  it 
is  resorted  to  for  the  removal  of  tracheal  growths  and  of  foreign 
bodies  lodged  in  the  larynx  or  the  bronchial  tubes.  The  tracheal 
opening  is  made  above,  through,  or  below  the  isthmus  of  the  thy- 
roid gland.  In  children  with  thick,  short  necks,  and  in  cases  in 
which  the  thyroid  gland  is  enlarged,  the  high  operation  should 
invariably  be  selected.  Ordinarily  the  high  operation  should  be 
performed,  more  especially  by   the   beginner  in  surgery,  as  it   is 


Carotis  interna  et 

externa 

Vena  facialis 
communis 
R.  descd.  N.  XII. 

Vena  jugularis 

interna. 
Vena  thyroid, 
superior. 

N.  phrenicus 
Scalenus  anticus 


Sternocleido- 

mastoideus 
Vena  facialis 

communis 
Thyrohyoid 

muscle 
Omohyoid 

muscle 
Sternohyoid 


Cartilage 
cricoidea 


Trapezius 


Arteria  cer- 
vicalis  superficialis     / 
Arteria  transversa 
colli 
Arteria  transversa  scapulae 

Vena  jugularis  externa 


Omohyoid 
Arteria  subclavia 

Sternocleidomastoideus 
Clavicula 
Isthmus  gland,  thyroid. 


Vena  thyroid,  inferior. 

Fig.  448. — Anatomy  of  the  neck,  with  special  reference  to  the  operation  of  tracheotomy 

(after  Henke). 


attended  by  fewer  technical  difficulties  than  the  median  or  low  oper- 
ation. 

The  median  operation  requires  preliminaiy  double  ligation  of 
the  i.sthmus  of  the  thyroid  gland,  which  is  then  cut  between  the  liga- 
tures. The  ligatures  of  silk  are  passed  between  the  trachea  and  the 
isthmus  of  the  gland,  one  on  each  side,  with  an  artery  needle,  and 
if  such  is  not  at  hand,  with  an  eyed  probe  or  Kochcr's  hemostatic 
forceps.  After  tying  firmly,  the  i.sthmus  is  cut  between  them,  after 
which  the  trachea  is  expcsed.  The  lo.ss  of  time  consumed  in  this 
preliminary  step  of  the  operation  is  an  imi:)ortant  item  in  determining 


646  EMERGENCY    OPERATIONS    ON    THE    AIR-PASSAGES. 

the  choice  of  operation  in  cases  in  which  the  symptoms  are  urgent. 
The  thermocautery  can  not  be  reHed  upon  as  a  hemostatic  m  divid- 
ing the  isthmus  of  the  gland,  and  forcipressure  is  objectionable  ; 
hence  if  the  median  route  is  chosen,  preliminary  double  ligation  of 
the  isthmus  with  silk  furnishes  the  only  security  against  troublesome 
hemorrhage.  If  the  neck  is  long,  the  panniculus  adiposus  scanty, 
and  the  trachea  prominent,  the  low  operation  presents  the  least 
difficulties  and  should  be  selected. 

In  children  the  high  operation  is  made  much  easier  by  including 
the  cricoid  cartilage,  thus  substituting  for  the  typical  tracheotomy 
cricotracheotomy.  In  opening  the  trachea  by  this  route  the  crico- 
thyroid membrane  should  not  be  cut,  thus  avoiding  injury  to  the 
cricothyroid  artery.  This  membrane  is  elastic  and  will  stretch  to 
the  requisite  extent  on  retracting  the  cricoid  and  tracheal  rings  pre- 
paratory to  the  insertion  of  the  cannula. 

A  so-called  rapid  tracheotomy  should  always  be  made  above  the 
thyroid  gland.  There  are  cases  in  which  the  trachea  must  be 
opened  instantaneously  by  one  cut — cases  in  which  one  minute's 
delay  might  result  in  death.  Impending  death  from  spasm  of  the 
larynx  caused  by  the  presence  of  a  foreign  body  or  sudden  obstruc- 
tion to  the  entrance  of  air  from  edema  in  inflammatory  affections  of 
the  larynx  are  the  conditions  that  demand  immediate  action  and  that 
preclude  a  careful  dissection  in  opening  the  larynx.  This  operation 
has  succeeded,  occasionally,  in  saving  a  life  when  performed  shortly 
after  respiration  has  ceased,  and  when  followed  by  systematic  and 
prolonged  artificial  respiration.  In  great  emergencies  of  this  kind 
it  would  be  justifiable  and  proper  to  open  the  trachea  with  one  stroke 
of  a  penknife,  to  open  the  way  for  successful  artificial  respiration. 

Rapid  tracheotomy  is  performed  by  placing  the  patient  in  the 
supine  position,  an  assistant  fixing  the  head  in  the  extended  posi- 
tion. The  surgeon,  standing  on  the  right  side  of  the  patient,  grasps 
the  larynx  and  upper  part  of  the  trachea  with  the  thumb,  index-, 
and  middle  fingers  of  the  left  hand,  notes  the  location  of  the  cricoid 
cartilage,  and  with  one  sweep  of  the  knife  divides  all  the  tissues, 
including  the  cricoid  cartilage  and  the  first  two  or  three  tracheal 
rings.  If  the  incision  is  made  as  it  should  be,  exactly  through  the 
median  line,  troublesome  hemorrhage  need  not  be  feared.  With  a 
view  to  preventing  the  blood  from  entering  the  bronchial  tubes  the 
head  and  neck  are  placed  in  a  dependent  position  until  the  hemor- 
rhage has  been  arrested.  Nothing  must  interfere  with  a  prompt 
resort  to  artificial  respiration.  If  a  cannula  is  at  hand,  it  is  at  once 
inserted,  using  the  tip  of  the  left  index-finger  in  the  wound  as  a 
guide  for  the  insertion  of  the  cannula  and  as  a  wedge  in  separating 
the  tracheal  rings.  If  respiration  has  become  suspended  before  or 
during  the  operation,  artificial  respiration  must  be  continued  as 
long  as  there  is  any  hope  of  reviving  the  patient.  If  any  mistake  is 
made  in  this  respect,  it  should  be  made  on  the  right  side,  as  appar- 
ently hopeless  efforts  are  occasionally  rewarded  by  success  if  they 


TRACHEOTOMY. 


647 


Fig.    449. — Trousseau's 
double  tracheotomy  tube. 


are  continued  for  a  sufficient  length  of  time.  Tracheotomy  under 
more  favorable  circumstances  must  be  made  by  careful  dissection, 
arresting  hemorrhage  as  the  operation  proceeds. 

In  adults  general  anesthesia  is  unnecessary,  as  the  operation  can 
be  made  almost  painless  by  Schleich's  infiltration  method,  by  inject- 
ing solution  No.  2  into  the  skin  along  the 
proposed  line  of  incision.  After  the  skin 
and  superficial  fascia  have  been  incised,  the 
wound  can  be  brushed  from  time  to  time 
with  the  same  solution,  or,  what  is  perhaps 
better  for  this  particular  purpose,  with  a  2 
per  cent,  solution  of  cocain.  In  children  the 
carbonic  dioxid  intoxication  has  frequentl}- 
reached  such  a  degree  at  the  time  the  opera- 
tion is  performed  that  the  administration  of 
a  general  anesthetic  can  be  dispensed  with. 
If  this  is  not  the  case,  chloroform  should  be  given  instead  of  ether, 
as  the  latter  irritates  the  inflamed  air-passages  and  causes  profuse 
salivation,  both  very  undesirable  effects  during  a  tracheotomy.  The 
addition  of  nitrite  of  amyl  to  the  chloroform,  in  the  proportion  of 
fifteen  minims  to  four  ounces,  will  facilitate  and  add  to  the  safety  of 
the  administration  of  the  anesthetic.  The  chloroform  is  to  be  ad- 
ministered continuously  and  very  slowly,  with  an  abundance  of  air. 
The  operation  should  be  performed  in  a  room  the  temperature 
of  which  must  be  at  least  75°  F.,  and  it  is  advisable  to  impregnate 
the  air  with  steam.  The  little  patient  should  be  properly  prepared 
for  the  operation  by  fastening  the  arms,  in  the  extended  position,  to 
the  side  of  the  body,  with  a  broad  towel   or  sheet  firmly  fastened 

with  safet}'-pins.  Proper  immobili- 
zation of  the  arms  is  an  important 
preparatory  step  to  the  performance 
of  a  tracheotomy.  The  next  step 
consists  in  placing  the  child  upon  a 
narrow  table,  in  the  most  convenient 
position,  which  consists  in  slight 
elevation  of  the  chest  and  full  ex- 
tension of  the  neck,  rendering  the 
larynx  and  trachea  prominent  and 
easy  of  access  (Fig.  447).  An  as- 
si.stant  sitting  at  the  head  of  the 
table  holds  the  head  immovably  in 
this  position  by  grasping  it  on  its 
sides  with  both  hands  well  expanded.  The  operator  stands  on  the 
right  side  of  the  patient,  opposite  his  assistant. 

The  instruments  required  for  this  operation  are  few  :  a  .scalpel, 
four  hemo.static  ff)rceps,  two  dis.secting  forceps,  sharp  and  blunt 
retractors,  Kocher's  director,  a  blunt  hook,  two  sharp  hooks,  an 
aneurysm  needle,  and  a  double  tracheotomy  tube  of  proper  size 


Fig.  450. — Cohen' .s  tracheotomy 
tubes. 


648  EMERGENCY    OPERATIONS    ON    THE    AIR-PASSAGES, 

constitute  the  necessary  instrument  supply  ;  in  an  emergency,  the 
operation  can  successfully  and  quickly  be  performed  with  a  scalpel 
and  two  dissecting  or  hemostatic  forceps.  The  Luer-Hagedorn  or 
Trousseau's  double  cannula,  without  a  fenestra,  is  the  one  in  gen- 
eral use,  and  has  given  the  best  satisfaction. 

Unless  there  are  special  objections  presented  by  the  case,  the 
high  operation,  including  section  of  the  cricoid  cartilage,  is  the  one 
the  general  practitioner  should  perform,  as  it  does  not  implicate 
the  thyroid  gland  and  involves  the  most  prominent  and  most  acces- 
sible part  of  the  trachea.  The  operator  satisfies  himself  of  the 
exact  location  of  the  cricothyroid  space,  between  the  cricoid  carti- 
lage and  the  most  prominent  part  of  the  larynx, — the  pomum 
adami, — and  begins  the  incision  directly  over  this  space  and  ex- 
actly in  the  middle  line,  extending  it  downward  for  at  least  two  or 
three  inches,  dividing  the  skin  and  superficial  fascia.  The  skin  is 
stretched  and  the  trachea  fixed  with  the  thumb  and  first  two  fingers 
of  the  operator's  left  hand.  The  great  secret  in  performing  the  op- 
eration quickly  and  safely  is  not  only  to  begin  in  the  median  line,  but 
also  to  follow  the  same  during  the  remaining  steps  of  the  operation 
until  the  trachea  has  been  reached,  and  to  arrest  hemorrhage,  as  it 

occurs,  by  the  free  use  of 
hemostatic  forceps,  zuhich 
not  only  serve  well  hi 
controlling  the  bleeding, 
but  to  some  extent  also 
take  the  place  of  retrac- 
Fig.  451. — Koenig's  long  tracheotomy  tube.  tors.       The  deep  connec- 

tive tissue  between  the 
sternohyoid  muscles  is  opened  between  dissecting  forceps  and  care- 
fully divided,  or,  what  is  safer,  after  it  has  been  opened,  is  torn  with 
the  dissecting  forceps  sufificiently  to  expose  these  muscles,  which 
are  then  retracted.  The  deep  fascia  in  front  of  the  trachea  is  next 
severed  with  blunt  instruments  as  far  as  the  isthmus  of  the  thyroid 
gland.  If  the  gland  is  large  and  in  the  way,  it  is  drawn  downward 
with  a  blunt  hook  by  an  assistant.  Before  the  trachea  is  opened 
each  bleeding  point  is  secured  with  hemostatic  forceps,  as  few,  if  any, 
ligatures  will  be  required  after  respiration  through  the  cannula  has 
been  fully  restored.  Opening  of  the  trachea  and  insertion  of  the 
cannula  are  the  final  and  most  important  steps  of  the  operation. 
Two  sharp  hooks  are  very  convenient  during  this  part  of  the  opera- 
tion. The  trachea  should  never  be  incised  until  the  rings  that  it  is 
necessary  to  incise  can  be  seen  as  well  as  felt.  The  violent  move- 
ments of  the  trachea  must  be  overcome  for  the  few  moments  re- 
quired in  dividing  the  rings  and  in  inserting  the  tube. .  The  two 
sharp  hooks  are  inserted  into  or  under  the  first  tracheal  ring,  a  few 
lines  apart,  one  held  by  the  operator  and  the  other  by  his  assistant, 
when  traction  is  made  upward  and  forward,  and,  at  the  same  mo- 
ment, the  cricoid  cartilage  and  the  first  two  tracheal  ring-s  are  in- 


TRACHEOTOMY. 


649 


Fig.  452. — Tracheotomy  ;    illustrating  the  manner  in  which  the 
tracheal  rings  should  be  cut  (Esmarch  and  Kowalzig). 


cised  in  the  middle  line  between  the  hooks.  On  making  lateral 
and  forward  traction  on  the  hooks  the  tracheal  wound  is  opened  for 
the  insertion  of  the  tube  (Fig.  452  exhibits  double  hook).  In  the 
absence  of  such  hooks  a  very  useful  substitute  can  be  extempor- 
ized by  passing 
a  strong  silk 
suture  with  a 
well-curved  nee- 
dle through  the 
tracheal  ring  on 
both  sides. 

In  incising 
the  trachea  it  is, 
of  course,  nec- 
essary to  guard 
against  injury  of 
the  posterior 
wall  of  the  tra- 
chea by  not 
penetrating  the 
trachea       much 

beyond  the  thickness  of  its  anterior  wall.  It  is  always  necessary 
to  cut  at  least  three  of  the  tracheal  rings.  If  the  trachea  is  to  be 
opened  below  the  cricoid  cartilage,  the  first  three  rings  are  incised. 
The  general  practitioner  will  very  seldom  perform  median  trache- 
otomy, as  this  operation  necessitates  cutting  of  the  isthmus  of  the 

thyroid  gland  between 
a  double  ligature. 

The  low  operation 
is  performed  in  the 
same  manner  as  the 
high,  except  that  the 
thyroid  gland  is  dis- 
placed upward  instead 
of  downward  by  insert- 
ing a  blunt  hook  un- 
derneath the  lower 
border  of  the  isthmus, 
the  assistant  making 
upward  traction  to  in- 
crease the  space  be- 
tween the  gland  and 
the  jugulum  of  the 
sternum.  As  has  been 
stated  before,  the  low  operation  is  occasionally  preferable  if  the 
neck  is  long  and  the  trachea  i)rominent.  After  the  in.sertion  of  the 
cannula,  the  surgeon's  first  attention  is  directed  toward  establishmg 
free  res[)i ration  through  the  artificial  inlet.      If  mucus,  membranes, 


Fig.  453. — Cannula  fastened  in  place. 


650  EMERGENCY    OPERATIONS    ON    THE    AIR- PASSAGES. 

or  blood  interfere  with  the  free  passage  of  air  in  both  directions, 
the  passage  in  the  cannula  and  trachea  is  cleared  by  using  a  feather 
or  cotton  mop  made  by  wrapping  cotton  around  a  wire  loop  and 
moistening  the  same  in  warm  salt  solution.  In  this  manner  frag- 
ments of  membrane  and  blood-clots  can  be  removed,  and  the 
passage  for  the  entrance  of  air  cleared.  If,  on  removing  the 
hemostatic  forceps,  any  of  the  vessels  bleed,  they  are  tied.  The 
cannula  is  fastened  in  place  with  two  tapes  sewed  to  the  shield,  and 
tied  securely  around  the  neck. 

The  wound  dressing  consists  of  a  few  layers  of  iodoform  gauze 
compress,  in  which  a  slit  is  made,  placed  underneath  the  shield  of 
the  cannula.  The  inner  tube  is  removed  from  time  to  time,  and 
after  thorough  cleansing  is  reintroduced.  The  air  in  the  sick-room 
should  be  kept  at  an  equable  temperature,  free  from  drafts,  and 
kept  saturated  with  salt  water,  steam,  or  vapor  from  slaking  quick- 
lime. Usually  at  the  end  of  a  week  or  two  the  permeability  of 
the  larynx  is  restored  and  the  cannula  can  be  dispensed  with,  but 
care  and  watchfulness  are  necessary  in  determining  the  time  when 
it  is  safe  to  remove  it. 

If  no  cannula  is  at  hand  when  a  tracheotomy  must  be  performed, 
some  kind  of  a  reliable  substitute  must  be  pressed  into  service.  The 
first  thing  that  suggests  itself  would  be  to  cut  a  circular  defect  in 
two  rings  of  the  trachea,  corresponding  in  size  to  the  tracheal  tube. 
Tubeless  tracheotomy  made  in  this  manner  was  warmly  advocated 
by  the  late  Henry  Martin,  of  Boston,  and  might  be  resorted  to  with 
confidence  in  case  no  proper  tube  could  be  secured.  Silk  threads 
passed  through  the  middle  tracheal  ring  on  each  side  and  tied  behind 
the  neck  with  sufficient  firmness  to  secure  enough  gaping  of  the 
tracheal  wound  to  permit  the  free  passage  of  air,  form  another 
valuable  substitute  for  the  tracheal  tube.  A  piece  of  rubber  tubing 
or  a  large  Nelaton  catheter  inserted  into  the  trachea  will  also 
answer  an  excellent  purpose  until  a  tube  of  proper  construction  can 
be  secured.  And,  lastly,  retractors  can  be  made  of  wire  or  hair- 
pins, which  can  be  used  to  retract  the  margins  of  the  tracheal 
wound  by  attaching  to  them  a  string  or  tape,  and  tying  the  same 
behind  the  arch. 

The  success  of  tracheotomy  rests  largely  on  the  care  with  which 
the  after-treatment  is  conducted.  There  is,  perhaps,  no  other  opera- 
tion in  surgery  in  which  unremitting  care  and  skill  are  better  re- 
warded, and  negligence  and  ignorance  more  severely  punished,  than 
after  tracheotomy  for  inflammatory  stenosis  of  the  larynx. 


CHAPTER  XVI. 

EMPYEMA. 

The  term  empyema  is  used  to  designate  the  presence  of  pus  in 
the  pleural  cavity  ;  practically,  it  means  the  existence  of  a  pleural 
abscess.  It  represents  the  pathologic  product  of  either  a  primary  or 
a  secondary  suppurative  pleuritis.  Suppurative  pleuritis  is  always 
the  result  of  a  pyogenic  infection  of  the  pleura,  sufficient  in  viru- 
lence to  give  rise  to  pus-formation.  In  the  absence  of  traumatic 
causes  it  appears  clinically  and  pathologically  either  as  an  isolated 
inflammation  of  the  pleura  or  as  a  more  or  less  remote  complication 
of  pneumonia.  Bacteriologically  speaking,  suppurative  pleuritis  can 
result  only  from  the  presence  in,  and  the  specific  action  upon,  the 
tissues  of  the  pleura  of  pyogenic  microbes  in  sufficient  number  and 
virulence  to  give  rise  to  a  suppurative  inflammation.  Nontraumatic 
suppurative  pleuritis  is  a  comparatively  rare,  isolated  affection  ;  in 
the  great  majority  of  cases  it  presents  itself  as  a  complication  of 
pneumonia.  Recent  investigations  tend  to  prove  that  the  essential 
cause  of  pneumonia  is  either  Frankel's  pneumococcus,  Friedlander's 
bacillus  of  pneumonia  (diplobacillus),  or  the  streptococcus  pyo- 
genes. In  rare  cases  the  bacillus  coli  communis  has  been  found  as 
the  principal,  if  not  the  sole,  microbic  cause  of  the  pleural  suppura- 
tion. Streptococcus  pneumonia,  occurring  as  either  a  primary  or 
secondary  affection,  is  characterized  clinically  by  the  gravity  of 
the  disease,  and  pathologically  by  the  intrinsic  tendency  to  pus- 
formation. 

The  microbes  ot  pneumonia,  discovered  by  Frankel  and  Fried- 
lander,  are  the  bacteriologic  agents  usually  found  in  the  inflamed 
tissues  in  croupous  pneumonia.  Both  of  these  microbes  possess 
feeble  intrinsic  pyogenic  properties,  and  when,  during  the  pneu- 
monic process,  abscess  formation  or  suppurative  pleuritis  sets  in, 
the  complication  occurs  usually  as  the  result  of  a  secondary  or 
mi.xed  infection  with  j^us-microbes.  Occasionally,  however,  the 
pneumococcus  is  found  as  the  sole  bacteriologic  cause  in  the  pus 
of  empyema  and  more  distant  foci  of  suppuration. 

Croupous  pneumonia  is  a  self-limited  disease,  and  when  febrile 
symptoms  persist  after  the  usual  lapse  of  time  required  for  the  dis- 
ease to  complete  its  typical  cycle,  it  is  usually  an  indication  that 
mixed  infection  has  occurred.  In  this  event  it  becomes  the  urgent 
duty  of  the  attending  physician  to  look  for,  locate,  and  determine, 
if  possible,  the  nature  of  the  complication  in  order  to  enable  him 
to  institute  timely  and  appropriate  therapeutic  measures.  Retarded 
resolution  and  continuance  of  fever,  or  reai^pcarance  of  fever  after 

651 


5C2  EMPYEMA. 

a  few  days  of  defervescence,  are  very  suggestive  of  a  beginning 
suppurative  pleuritis.  Many  serious  mistakes  have  been  made  by 
not  subjecting  patients  to  repeated  and  careful  examinations  during 
this  critical  stage.  A  progressive  increase  in  the  area  of  dullness, 
with  or  without  a  continuance  of  febrile  symptoms,  at  a  time  when, 
under  ordinary  circumstances,  resolution  should  have  been  in  pro- 
gress or  completed,  is  very  strong  evidence  of  the  existence  of  a 
complicating  suppurative  pleuritis.  In  suppurative  pleuritis  occur- 
ring as  a  secondary  affection  to  pneumonia,  the  inflamed  lung  tissue 
is  seldom  involved  in  the  suppurative  process.  Resolution  may 
proceed  in  a  satisfactory  manner  at  the  time  and  after  the  suppura- 
tive pleuritis  has  set  in,  a  fact  that  would  tend  to  prove  that  the 
parenchyma  of  the  lung  is  more  resistant  to  the  action  of  pyogenic 
microbes  than  the  tissues  of  the  pleura,  or  that  these  microbes  find 
their  way  more  readily  to  the  pleura  than  into  the  pneumonic  focus 
after  secondary  infection  has  occurred. 

The  complicating  secondary  pleuritis  manifests  itself  usually 
about  the  time  the  crisis  is  expected  or  a  few  days  later.  It  is  evi- 
dent that  the  suppurative  complication  in  cases  of  pneumonia 
would  be  likely  to  appear  in  cases  in  which  the  tissues  are  rendered 
susceptible  to  the  action  of  pus-microbes,  and  under  circumstances 
that  would  supply  the  bacteria  for  the  secondary  mixed  infection. 
A  corroboration  of  the  correctness  of  the  statement  was  furnished 
by  observations  at  Camp  George  H,  Thomas,  at  Chickamauga, 
during  the  Spanish-American  war.  Pneumonia  of  a  severe  type 
was  prevalent  during  the  spring  months.  It  was  observed  that  em- 
pyema occurred  most  frequently  in  parts  of  the  camp  where  dust 
was  most  abundant.  In  some  parts  of  the  camp  comparatively  free 
from  dust  no  cases  of  empyema  occurred,  although  the  sick-reports 
showed  the  usual  percentage  of  pneumonia.  It  is  more  than  prob- 
able that  in  most  of  the  cases  of  secondary  suppurative  pleuritis 
the  pyogenic  microbes,  which  eventually  attacked  the  pleura  and 
caused  the  suppurative  process,  entered  the  lungs  at  the  same  time 
and  in  the  same  manner  as  the  microbes  that  produced  the  pneu- 
monia. The  bronchitis  and  diarrhea  that  initiated  the  disease  were 
plain  evidences  pointing  in  this  direction.  In  some  of  the  cases  in 
which  the  pneumonia  pursued  a  typical  course  the  subsequent  sup- 
purative pleuritis  was  caused  by  a  secondary  mixed  infection. 

The  limited  means  at  Camp  George  H.  Thomas  for  making  a 
satisfactory  bacteriologic  examination  of  the  inflammatory  product 
made  it  impossible  to  ascertain,  in  each  case,  the  nature  of  the 
microbic  cause.  In  two  of  the  cases  inoculation  of  proper  nutrient 
media  resulted  in  an  abundant  growth  of  the  staphylococcus 
pyogenes  aureus.  There  can  be  but  little  doubt  that  in  most,  if  not 
in  all,  cases  the  suppurative  pleuritis  developed  in  consequence  of 
a  secondary  infection  with  pus-microbes,  probably  in  most  instances 
with  the  staphylococcus,  as  indicated  by  the  clinical  course  of  the 
disease  and  the  nature  of  the  inflammatory  product. 


DIAGNOSIS.  653 

The  influence  of  dust  in  the  causation  of  pneumonia  and  suppu- 
rative pleuritis  acts  in  two  ways  : 

1.  The  mechanical  irritation  of  the  bronchial  mucous  mem- 
brane resulting  from  the  presence  of  ordinary  dust  renders  the 
epithelial  layer  of  the  bronchial  mucous  membrane  more  permeable 
to  the  entrance  of  pathogenic  microbes. 

2.  Pathogenic  microbes,  and  in  this  case  pus-microbes,  are 
suspended  in  the  dust  and  find,  with  it,  entrance  into  the  air- 
passages. 

Nontraumatic  primary  suppurative  pleuritis  is  the  result  of  a 
hematogenous  infection.  The  disease  often  comes  on  insidiously. 
It  is  sometimes  difficult  to  trace  the  beginning  of  the  disease  ;  pain 
in  the  side  and  a  slight  rise  in  temperature,  with  a  gradually  increas- 
ing shortness  of  breath,  are  often  the  only  symptoms  that  attract 
the  attention  of  the  patient. 

This  form  of  the  disease  is  due  to  a  very  mild  form  of  pyogenic 
infection.  The  effiision  takes  place  rapidly,  and  consists,  at  first,  of 
a  slightly  turbid  serum,  which  under  the  microscope  exhibits  only 
a  limited  number  of  pus-corpuscles.  The  pus-corpuscles,  however, 
in  time  increase  in  number,  and  finally  this  inflammatory  product 
consists  of  a  thin,  serous  pus.  Fibrinous  exudates  are  scanty  or  are 
entirely  absent.  By  repeated  tappings  I  have  observed  the  difierent 
stages  of  pus-formation  from  almost  clear  serum  to  well-marked 
empyema.  In  the  more  acute  form  of  empyema  the  general  and 
local  symptoms  are  much  more  violent.  The  disease  is  usually 
initiated  by  a  chill,  followed  by  a  rapid  rise  in  temperature,  remain- 
ing, with  some  daily  variations,  for  some  time,  but  may  become 
normal  after  several  days  or  weeks,  with  the  pleural  cavity  full  of 
pus.  The  absence  of  elevated  temperature  is,  in  such  cases,  as 
under  some  other  circumstances,  no  positive  proof  of  the  absence 
of  pus.  The  general  practitioner  usually  associates  pus  with  tem- 
perature, and  by  so  doing  mistakes  in  diagnosis  are  frequently  made 
and  timely  surgical  aid  postponed  or,  perhaps,  goes  entirely  by  de- 
fault. The  pleuritic  stitch  in  the  side  is  a  constant  symptom  in  acute 
suppurative  pleuritis,  and  is  usually  attended  by  a  dr\',  hacking 
cough.  The  inflammatory  product  consists  of  more  or  less  fibrinous 
exudate  and  pus.  In  some  cases  the  fibrinous  exudate  is  very  copi- 
ous, covering  both  the  visceral  and  parietal  pleura;,  and  constituting 
a  considerable  portion  of  the  contents  of  the  abscess  in  the  form  of 
large  fibrinous  masses  mixed  with  the  thick,  cream-like  pus.  This 
fibrinous  product  is  invariably  infected  with  pus-microbes,  and  hence, 
if  not  removed  at  the  time  the  radical  operation  is  performed,  serves 
to  maintain  suppuration  indefinitely. 

Diagnosis. — The  history  of  the  case  and  the  .signs  and  .symptoms 
presented  by  suppurative  pleuritis  are  often  sufficient  to  enable  the 
physician  to  make  a  probable  diagnosis  of  empyema.  A  positive 
diagnosis  exacts  demonstrative  evidences  of  the  presence  of  pus  in 
the  pleural  cavity.      Such  indications   are   furnished   by  rupture  of 


654  EMPYEMA. 

the  empyema  into  a  bronchial  tube  and  the  sudden  expectoration  of 
a  large  quantity  of  pus  by  coughing,  the  escape  of  the  chest  con- 
tents between  two  ribs,  and  the  formation  in  the  connective  tissue 
of  an  abscess  in  communication  with  the  pleural  cavity  (empyema 
necessitatis),  or  by  resorting  to  an  exploratory  puncture.  Obliter- 
ation and  bulging  of  the  intercostal  spaces  over  a  limited  area  and 
edematous  swelling  of  the  skin  are  strong  indications  of  the  exis- 
tence of  pus  in  the  pleural  cavity,  the  suspicion  of  such  a  condition 
being  strengthened  by  redness  of  the  overlying  skin.  Displacement 
of  the  heart  and  liver,  dullness  on  percussion,  absence  of  respiratory 
sounds,  enlargement  of  the  affected  side  of  the  chest,  and  diminished 
respiratory  movements  are  physical  signs  that  point  to  the  existence 
of  fluid  in  the  cavity  of  the  chest,  but  they  are  of  little  value  in  dif- 
ferentiating between  empyema  and  hydrothorax.  The  change  in 
the  level  of  the  fluid,  caused  by  placing  the  chest  in  different  posi- 
tions and  ascertained  by  percussion,  is  more  marked  in  hydrothorax 
than  in  empyema,  because  in  the  latter  condition  the  copious  fibrin- 
ous exudate  immobilizes  the  lung  and  walls  in  the  inflammatory 
product.  /;/  the  absence  of  positive  indications  of  the  presence  of  pns 
in  the  pleural  cavity  Jio  operation  should  be  undertaken  witJiout  resort- 
ing to  an  exploratory  puncture  for  the  purpose  of  demonstrating  the 
presence  and  exact  location  of  the  intrapleural  abscess.  An  explora- 
tory puncture  is  attended  by  so  little  risk  and  pain  that  its  employ- 
ment as  a  diagnostic  resource  should  never  be  neglected. 

Surgical  Treatment  of  Empyema. — Medical  treatment  has  no 
curative  influence  on  empyema.  Internal  treatment  by  the  admin- 
istration of  tonics  and  stimulants  is  indicated,  as  in  other  suppura- 
tive affections,  to  maintain  the  general  strength  of  the  patient  and 
the  heart's  action,  but  it  is  of  no  value  in  the  removal  of  the  in- 
flammatory product.  As  soon  as  a  positive  diagnosis  of  empyema 
can  be  made,  the  old  teaching,  ubi  pus  ibi  evacjio,  is  in  force,  and 
must  be  followed  without  much  delay.  Late  diagnosis  and  delayed 
operations  are  responsible  for  many  unsatisfactory  recoveries,  as 
prolonged  pulmonary  compression  and  adhesions  are  the  most 
potent  causes  of  subsequent  imperfect  expansion  of  the  compressed 
lung.  The  existence  of  an  empyema  in  the  adult  is  a  sufficient 
indication  for  the  performance  of  a  radical  operation.  Puncture 
and  removal  of  the  pus  by  aspiration  may  succeed  occasionally  in 
mild  cases  of  suppurative  pleuritis  in  the  case  of  children  ;  seldom, 
if  ever;  in  the  adult.  In  the  case  of  empyema  puncture  followed 
by  drainage  and  permanent  aspiration,  as  advised  by  Biilau,  may  be 
tried  for  a  limited  length  of  time,  but  if  it  fails,  should  be  followed, 
without  unnecessary  harmful  delay,  by  a  radical  operation. 

Aspiration  drainage  is  made  by  inserting  a  trocar  of  ample  size 
in  the  axillary  line  at  the  most  dependent  point  of  the  empyemic 
cavity,  and  by  inserting  a  Nelaton  elastic  catheter  into  the  lumen 
of  the  cannula  after  withdrawing  the  stilet.  The  catheter  should 
fill  the  lumen  of  the  instrument  accurately,  so  that,  on  the  removal 


SURGICAL    TREATMENT    OF    EMPYEMA. 


655 


of  the  cannula,  the  tissues  of  the  tunnel  made  by  the  trocar  will 
grasp  the  drain,  preventing  leakage  and  the  entrance  of  air.  The 
drain  is  fastened  to  the  surface  of  the  chest  with  collodion  and  a 
few  thin  layers  of  absorbent  aseptic  cotton.  The  catheter  is  con- 
nected with  a  long  piece  of  rubber  tubing  by  a  short  glass  tube, 
and  the  distal  end  of  the  rubber  tube  is  immersed  in  a  vessel  hold- 
ing an  antiseptic  solution  and  placed  at  the  side  of  the  bed,  two  or 
three  feet  below  the  level  of  the  chest.  When  the  vessel  is  full,  its 
contents  are  poured  out  and  it  is  disinfected.  After  emptying  the 
rubber  tube  by  stripping  it  from  the  glass  tube  in  a  downward 
direction,  the  distal  end  is  again  immersed  in  the  new  antiseptic 
solution.  By  siphon  action  the  pleural 
cavity  is  gradually  emptied  of  its  con- 
tents, and  so  long  as  the  siphon  drain- 
age is  in  good  condition,  reaccumula- 
tion  is  prevented.  If  the  patient  is 
manageable  and  of  sufficient  intelli- 
gence, he  can  leave  his  bed  in  a  few 
days  without  interfering  with  drainage, 
by  carrying  the  receptacle  in  a  pocket 
below  the  level  of  the  puncture  (Fig. 
454).  In  well-marked  cases  of  em- 
pyema in  the  adult  nothing  is  gained 
by  this  method  of  treatment.  A  radi- 
cal operation  should  be  performed  as 
soon  as  a  diagnosis  can  be  made. 
Unless  the  signs  and  symptoms  are 
conclusive,  the  diagnosis  must  be 
verified  and  the  pus  accurately  located 
by  an  exploratory  puncture.  Nothing 
is  gained  and  much  is  lost  by  post- 
poning a  radical  operation  until  the 
accumulated  pus  has  increased  to  the 
extent  of  producing  serious  and  often 
irremedial  compression  of  the  lung  on 
the  affected  side.  The  plastic  exudate, 
which  is  often  copious,  is  another  source  of  danger  in  case  the 
operation  is  delayed,  as  it  creates  mural  adhesions  unfavorable  to 
the  subsequent  expansion  and  restoration  of  function  of  the  com- 
pressed lung,  and  extenuates  indefinitely  the  infection. 

In  view  of  the  pathologic  anatomy  exhibited  by  cases  of  em- 
pyema it  must  be  admitted  that  the  only  rational  treatment  consists 
in  opening  the  pleural  cavity  freely  and  in  establi.shing  efficient 
tubular  drainage.  The  abscess  walls  in  empyema  are  more  or  less 
un)'ielding,  hence  the  provision  must  be  made  to  maintain  adequate 
drainage  until,  by  gradual  reduction  in  the  size  of  the  cavity  by  ex- 
pansion of  the  lung,  retraction  of  the  chest-wall,  ascent  of  the  dia- 


Fig.  454. — Biilau's  aspiration 
drainage  of  the  pleural  cavity  (Es- 
march  and  Kowalzig). 


5^6  EMPYEMA, 

phragm,  and  a  process  of  granulation  and  cicatrization,  further 
drainage  can  be  dispensed  with  without  fear  of  a  relapse. 

Incision  of  the  chest- wall  for  the  liberation  of  pus  is  an  ancient 
procedure.  Hippocrates  came  to  the  conclusion  that  incision 
through  an  intercostal  space  did  not  furnish  a  sufficiently  free  outlet 
for  the  pus,  and  advised  trephining  of  a  rib  over  the  pleural  abscess 
as  an  additional  mechanical  means  of  effecting  free  evacuation  of  the 
contents  of  an  empyemic  cavity.  This  operation  was  later  revived 
and  given  considerable  prominence  by  Dr.  Stone,  of  New  Orleans. 
In  children  intercostal  incisions  and  drainage  will  suffice  ;  in  adults 
with  more  unyielding  chest-walls,  subperiosteal  rib  resection  should 
always  be  made  as  a  preHminary  step  to  incision  of  the  empyemic 
cavity  to  insure  free  and  permanent  drainage.  I  had  an  extensive 
experience  in  incising  and  draining  the  pleural  cavity  through  the 
intercostal  spaces  before  rib  resection  became  a  well-established 
surgical  procedure.  Drains  of  metal  and  rubber  often  gave  rise  to 
great  pain  from  pressure,  and  in  chronic  cases  the  painful  effects  of 
prolonged  intercostal  pressure  were  often  seen  in  the  form  of  ex- 
tensive semilunar  defects  of  the  margins  of  the  adjacent  ribs,  re- 
vealed at  postmortem  or  subsequent  radical  operation  by  rib  re- 
section. 

Koenig  deserves  a  great  deal  of  credit  for  having  so  persistently 
urged  the  necessity  of  resection  of  a  section  of  a  rib  as  an  essential 
part  of  every  radical  operation  for  empyema.  Rib  resection  does 
not  increase  the  immediate  risks  of  the  operation  to  any  extent,  and 
the  advantages  gained  from  it  in  securing  free  and  permanent  drain- 
age more  than  balance  any  additional  dangers  incident  to  the  opera- 
tion, by  establishing  an  opening  in  the  chest-wall  well  adapted  for 
free  and  prolonged  drainage. 

The  proper  method  of  preparing  the  way  for  free  and  prolonged 
drainage  of  the  pleural  cavity  is  by  subperitoneal  resection  of  three 
or  four  inches  of  a  rib  at  the  most  dependent  part  of  the  empyemic 
cavity.  In  the  absence  of  contraindications  the  axillary  line  is 
selected  for  the  operation,  at  a  point  corresponding  to  the  lowest 
level  of  the  suppurating  cavity.  It  is  interesting  to  know  that  every 
intercostal  space,  from  the  first  to  the  last,  has  been  recommended 
at  different  times  as  the  most  important  point  of  attack  for  the  opera- 
tion for  empyema.  High  operation  is  objectionable  because  it  does 
not  secure  free  and  complete  evacuation  of  the  cavity,  and  an  open- 
ing low  down  is  apt  to  become  subsequently  obstructed  by  ascent 
of  the  diaphragm.  If  the  empyema  is  not  circumscribed  and  local- 
ized, it  is  important  to  open  the  chest  in  the  axillary  line,  where  the 
ribs  are  nearest  the  skin  and  near  the  base  of  the  pleural  abscess. 
The  seat  of  operation  must  be  determined  beforehand  by  a  careful 
physical  examination  and,  if  need  be,  by  an  exploratory  puncture. 
-In  cases  of  extensive  empyema  complicated  by  great  embarrass- 
ment of  the  respiratory  function,  it  is  advisable  to  resort  to  a  pre- 
liminary aspiration  of  the  chest  to  relieve  the  urgent  symptoms  and 


SURGICAL    TREATMENT    OF    EMPYEMA.  657 

to  prepare  the  way  for  a  more  speedy  and  satisfactory  expansion  of 
the  compressed  lung.  Prehminary  aspiration  is  of  special  value  in 
the  treatment  of  large  empyemic  cavities.  The  radical  operation 
must  be  performed  under  the  most  careful  aseptic  precautions,  as 
the  opening  of  large  pus-cavities  is  attended  by  great  responsibility  ; 
this  is  more  especiall}-  true  in  emp)'ema,  as  secondary  infection  is 
liable  to  occur  unless  the  operation  is  performed  under  the  most 
pedantic  aseptic  precautions.  The  whole  side  of  the  chest  must  be 
disinfected,  and  the  instruments  and  drains  employed  must  be  made 
faultlessly  aseptic.  If  an  anesthetic  is  given,  the  greatest  watchful- 
ness is  required.  It  is  advisable  to  operate  under  local  anesthesia 
by  Schleich's  infiltration  method  or  under  partial  general  anesthe- 
sia, and  strychnin  and  alcohol  should  be  administered  as  valuable 


f"'g-  455- — Curved  incision  for  exposing  rib  for  resection. 

prophylactics  in  guarding  against  the  immediate  and  remote  risks 
of  the  operation. 

The  patient  should  be  placed  partly  on  the  opposite  side,  with 
the  chest  slightly  elevated,  and  the  arm  on  the  side  to  be  operated 
upon  raised  to  the  side  of  the  head,  for  the  purpose  of  increasing 
the  width  of  the  intercostal  spaces.  In  exposing  the  rib  to  be 
resected,  I  make  a  slightly  curved  incision,  with  the  convexity 
directed  downward,  beginning  the  incision  at  a  point  corresj^onding 
with  the  upper  border  of  the  rib,  carrying  it  in  a  gentle  curve  to 
the  lower  border,  and  terminating  it  at  the  upper  border  at  a  point 
about  four  inches  from  where  it  started.  By  reflecting  the  cutane- 
ous shallow  oval  flap  in  an  upward  direction,  the  muscular  covering 
of  the  rib  is  expo.sed.  A  straight  incision  over  the  center  of  the 
rib  down  to  the  bone,  about  three  inches  and  a  half  in  length,  is 
then  made.  With  an  elevator  the  periosteal  envelop,  with  the  tissues 
attached  to  it,  is  then  separated,  taking  care  to  lift  out  from  its 
groove  at  the  lower  border  of  the  rib  the  intercostal  artery,  with 
42 


658 


EMPYEMA. 


the  tissues  to  be  reflected.  The  intercostal  vessels  and  nerve  are 
safe,  provided  the  operator  will  hug  the  bone  closely  in  separating 
the  periosteum  with  the  elevator.  After  laying  bare  the  rib  to  the 
extent  of  at  least  three  inches,  the  bone  is  lifted  forward  with  the  ele- 
vator and  excised  with  a  strong  pair  of  bone-cutting  forceps.  Several 
kinds  of  bone-cutting  forceps  have  been  invented  for  this  special 
purpose,  but  if  the  operator  feels  himself  in  need  of  a  bone-cutting 
forceps  of  special  construction,  he  should  provide  himself  with  an 
ordinary  pair  of  pruning  shears,  used  by  gardeners  and  sold  in 
every  hardware  store.  Saws  of  any  kind  are  to  be  avoided  in 
making  a  rib  resection.  If  the  diagnosis  is  positive,  all  that  remains 
to  be  done  after  rib  resection  is  to  make  an  incision  with  the  scalpel 
in  the  center  of  the  peritoneal  trough,  large  enough  to  admit  the 
tip  of  the  index-finger.  If  any  doubt  remains  as  to  the  exact  loca- 
tion of  the  pus  cavity,  an  exploratory  needle  is  used  to  locate  the 


Fig.  456. — Section  of  rib  with  bone-cutting  forceps. 

same  after  the  rib  resection  has  been  made.  The  cvaaiation  of  the 
chest  contents  should  always  be  done  slowly ;  this  can  be  accomplished 
most  effectually  by  interrupting  the  flow  of  pns  from  time  to  time  by 
plugging  the  pleural  incision  ivith  the  tip  of  the  index-finger.  After 
evacuation  of  the  pus  and  loose  shreds  of  fibrinous  material,  the 
pleural  cavity  should  be  carefully  examined  by  direct  inspection 
and  digital  exploration.  Reflected  light  is  an  important  aid  in 
making  the  visual  examination.  Plastic  exudates  loose  in  the  cavity 
and  attached  to  either  pleura  must  be  removed  as  thoroughly  as  can 
be  done  ivith  the  finger  and  a  small  ga2ize  sponge  held  securely  in  a 
sponge-holder  or  the  jaws  of  a  pair  of  long,  preferably  slightly  curved, 
forceps.  The  membranes  should  be  removed  by  mopping  and  not  by 
the  use  of  sharp  instruments.  Scraping  of  the  pleura  with  a  sharp 
spoon  is  superfluous,  and  occasionally  detrimental.  In  acute  cases 
free  hemorrhage  often  takes  place  from  the  pleural  surfaces,  even 


SURGICAL    TREATMENT    OF    EMPYEMA. 


659 


after  gentle  efforts  to  dislodge  the  adherent  fibrinous  exudate. 
Should  troublesome  hemorrhage  follow  the  procedure,  packing  the 
pleural  cavity  with  one  long  strip  of  plain  sterile  gauze  should  at 
once  be  resorted  to,  as  the  loss  of  any  considerable  amount  of 
blood  in  such  cases  might  prove  disastrous.  The  space  below  the 
drainage  opening  is  packed  first,  and  if  the  hemorrhage  is  not 
arrested,  the  remainder  of  the  cavity  is  packed  from  above  downward. 
Tubular  drainage  is  the  ideal  method  of  draining  a  suppurating 
pleural  cavit}\  Two  fenestrated  tubular  drains  the  size  of  the  little 
finger  and  about  four  inches  in  length,  securely  fastened  together 
with  a  large  safety-pin  or  a  stitch  through  each  end,  should  be  used 
for  this  purpose.  This  precaution  is  absolutely  necessary,  as  drains 
have  been  frequently  lost  in  the  pleural  cavity  for  want  of  securing 
with  a  large  safety-pin.  After  inserting  the  tubular  drain,  the 
external  wound    is   sutured    in   the    usual    manner.       The    curved 


Fig.  457. — External  wound  partly  sutured  ;  double  drain  in  place. 

incision,  as  previously  described,  not  only  exposes  the  rib  more 
freely  than  the  straight  incision  as  usually  practised,  but  also  is 
much  better  adapted  for  efficient  prolonged  drainage.  It  is  not 
advi.sablc  to  irrigate  the  cavity  the  day  the  operation  is  performed, 
and  irrigation  at  this  time  is  always  contraindicatcd  if  the  emp\emic 
cavity  is  in  communication  with  the  bronchial  tubes.  Irrigation  may 
become  necessary  later  if  the  suppuration  continues.  If  irrigation 
becomes  necessary  at  any  time,  care  must  be  exercised  in  the  selec- 
tion f)f  the  antiseptic  solution  ;  carbolic  acid  and  corrosive  subli- 
mate in  the  usual  strength  are  dangerous  and  should  never  be  used. 
A  nontoxic  and  yet  potent  antiseptic  solution  should  be  used — 
either  a  .saturated  solution  of  acetate  of  aluminum  or  Thiersch's 
solution.  ICither  of  these  solutions  is  efficient  as  an  antise[)tic,  and 
nontoxic  even  when  u.sed  in  large  quantities.  The  value  of  the 
double  drain  is  made   more  a[jparent  when  it  becomes  necessary  to 


66o 


EMPYEMA. 


irrigate  the  pleural  cavity.  By  placing  the  patient  on  the  opposite 
side  the  fluid  that  enters  the  chest  through  one  of  the  tubes 
escapes  through  the  other  as  soon  as  the  cavity  is  full,  thus  wash- 
ing it  out  thoroughly.  By  placing  the  patient  on  the  affected  side 
the  cavity  is  emptied,  when  the  same  procedure  is  repeated  until 
the  solution  returns  clear.  The  solution  used  must  always  be 
heated  to  blood  temperature,  as  irrigation  with  a  cold  solution  is 
fraught  with  danger.  I  have  seen,  in  the  case  of  a  child,  almost 
fatal  collapse  attend  irrigation  of  the  pleural  cavity  with  a  solution 

at  room-tempera- 
ture. It  required 
persistent  and  pro- 
longed efforts  to 
restore  the  sus- 
pended respiration 
by  the  administra- 
tion of  stimulants 
and  artificial  res- 
piration. 

The  external 
dressing  consists 
of  a  large  and 
thick  cushion  of 
sterile  gauze  and 
cotton  to  absorb 
the  fluid  as  fast  as 
it  escapes,  and,  at 
the  same  time,  to 
provide  the  wound 
with  a  filter  to  pre- 
vent postoperative 
infection.  There 
is  no  special  ad- 
vantage in  using 
medicated  in  place 
of  sterile  absorb- 
ent material,  so 
long  as  the  com- 
press is  removed,  as  it  should  be,  as  soon  as  indications  of  satura- 
tion appear  on  its  surface.  The  best  way  to  retain  the  dressing  in 
place  and  to  prevent  the  entrance  into  the  pleura  of  unfiltered  air 
is  to  substitute  for  the  ordinary  bandage  the  rubber-webbing  ban- 
dage, or  to  place  over  the  gauze  roller,  over  the  upper  and'' lower 
margin  of  the  dressing,  a  band  of  the  rubber-webbing  bandage. 
Change  of  dressing  and  antiseptic  irrigation  become  necessary  as 
often  as  the  dressing  becomes  saturated.  For  the  purpose  of  obvi- 
ating frequent  changes  the  dressings  should  be  at  least  six  inches 
thick  and  cover  the  whole  side  of  the  chest.     As  the  cavity  dimin- 


Fig-  458. — Dressing  after  operation  for  empyema. 


SURGICAL    TREATMENT    OF    EMPYEMA. 


66 1 


ishes  in  size  the  drains  are  shortened  from  time  to  time,  and  sooner 
or  later  one  of  them  can  be  dispensed  with.  Premature  removal  of 
the  drain  is  often  followed  by  relapse ;  drainage  must  not  be  sus- 
pended until  the  surgeon  can  satisfy  himself  by  carefid  examination 
that  the  pleural  cavity  has  become  obliterated.  Should  the  lung  fail 
to  expand  sufficiently  in  the  course  of  a  few  months  to  place  the 
cavity  in  a  condition  for  definitive  healing,  Schede's  thoracoplasty 
is  the  operation  of  choice,  as  Estlander's  multiple  rib  resection  has 
not  yielded  the  expected  results  in  the  practice  of  many  operators, 
including  my  own. 

It  is  well  for  the  surgeon  to  keep  close  watch  on  the  size  of  the 
empyemic  cavity  during  the  after-treatment,  not  only  for  the  pur- 
pose of  keeping  himself  well  informed  of  the  progress  of  the  heal- 
ing process,  but  also  with  a  view  to  determining  the  time  when  it  is 
safe  to  abandon  drainage.  For  a 
long  time  it  has  been  my  custom 
to  place  my  patient,  at  stated  in- 
tervals, on  the  opposite  side,  then 
to  fill  the  cavity  with  one  of  the 
antiseptic  solutions  used  for  irriga- 
tion, then  evacuate  the  chest  by  re- 
versing the  position,  and  measure 
the  quantity  of  fluid  removed.  This 
procedure  can  be  relied  upon  in 
giving  the  size  of  the  cavity,  and 
should  be  employed  systematically 
at  fixed  intervals,  to  ascertain  the 
proper  time  for  the  removal  of  the 
drain.  Schede's  thoracoplastic  op- 
eration is  a  grave  one,  and  should 
never  be  undertaken  without  clear 
and  well-defined  indications.  It  is 
attended  by  a  degree  of  shock 
equivalent  to  that  attending  an 
amputation  at  the  shoulder-joint 
general  condition  of  patients  upon 
is  often  such  as  to  require  the  most  careful  preliminary  preparation, 
in  order  to  minimize  the  immediate  risks.  It  has  yielded  en- 
couraging results  in  cases  of  empyema  complicating  pulmonary 
tuberculosis,  in  instances  in  which  the  extent  of  the  primary  dis- 
ease furnished  no  contraindication  to  the  operation. 

The  operation  consists  in  excising  the  wall  of  the  chest,  includ- 
ing the  pleura  and  intercostal  muscles,  leaving  the  skin  and  the 
muscles  outside  of  the  chest-wall  proper  in  the  form  of  a  large  oval 
flap,  which  is  then  brought  in  immediate  contact  with  the  collapsed 
lung.  The  incision  is  commenced  over  the  anterior  border  of  the 
pectoralis  minor,  on  a  level  with  the  axillary  space,  and  is  extended 
downward   in   a  curved   line  t(j  the  lower  limit   of  the   [)leura,  and 


Fig.  459- 


Line  of  incision  for  Schede's 
thoracoplasty. 


or    base    of    the    thigh.      The 
whom  it  must    be    performed 


662  PERITONITIS. 

continued  in  a  similar  curve  upward,  between  the  spine  and  the 
scapula,  as  far  as  the  second  rib.  All  the  soft  tissues,  including  the 
scapula,  are  reflected  upward  in  the  shape  of  an  enormous  flap 
(Fig.  459).  AH  the  ribs  from  the  second  downward  are  detached 
from  the  cartilages  with  a  cartilage  knife  or  bone-cutting  forceps. 
After  incising  the  pleura  to  the  same  extent,  the  pleural  cavity  is' 
freely  laid  open  for  inspection.  The  remainder  of  the  thorax  wall  is 
then  separated  by  cutting  rib  after  rib  with  bone-cutting  forceps, 
seizing  and  tying  the  intercostal  arteries  after  section  of  each  rib. 
After  cleansing  the  cavity  by  mopping  and  the  careful  use  of  the 
sharp  spoon  and  thorough  disinfection,  the  flap  is  brought  in  posi- 
tion and  in  contact  with  the  large  wound  surface.  Besides  a  few 
sutures,  the  external  dressing  is  relied  upon  in  maintaining  contact 
of  the  flap  with  the  underlying  wound  surface.  This  is  the  typical 
Schede's  thoracoplasty  for  the  treatment  of  large  empyemic  cavities. 
If  the  empyema  is  circumscribed,  the  resection  of  the  chest-wall  is 
made  in  the  same  manner,  but  to  a  less  extent,  as  it  would  not  be 
prudent  to  extend  the  resection  beyond  the  limits  of  the  suppurat- 
ing cavity. 


CHAPTER  XVll. 

PERITONITIS. 

Peritonitis  of  a  nontraumatic  origin  is  a  disease  that  comes 
most  frequently  under  the  care  of  the  general  practitioner.  Modern 
pathology  teaches  us  that,  with  few  exceptions,  it  occurs  as  a  sec- 
ondary lesion  as  the  result  of  an  extension  of  infection  from  a  more  or 
less  localized  suppurating  focus,  or  in  consequence  of  a  perforation 
in  any  part  of  the  gastro-intestinal  canal.  Peritonitis  as  observed 
in  connection  with  appendicitis,  salpingitis,  and  perforating  typhoid 
ulcer  furnishes  interesting  clinical  illustrations  of  the  advances  made 
in  the  investigation  of  its  etiology  and  pathology. 

Death  from  peritonitis  usually  occurs  from  septic  intoxication. 
For  the  purpose  of  gaining  access  to  and,  if  found,  of  removing  or 
rendering  harmless  the  original  cause,  and  with  a  view  to  securing 
an  outlet  for  the  septic  material  from  the  peritoneal  cavity,  laparot- 
omy has  largely  taken  the  place  of  the  expectant  treatment.  Thou- 
sands of  lives  are  saved  annually  by  timely  surgical  intervention, 
which,  under  the  former  routine  of  medical  treatment,  would  have 
been  doomed  to  certain  death.  The  progressive  physician  makes 
a  careful  study  of  every  case  of  peritonitis  and  watches  for  indi- 
cations for  operation,  avaiUng  himself  of  timely  surgical  aid  when- 
ever they  present  themselves. 

Peritonitis  is  characterized  by  a  complexus  of  symptoms,  con- 
sistmg  of  fever,  rapid,  wiry  pulse,  pain,  tenderness,  muscular  'rigid- 


plath 


ANATOMIC    CLASSIFICATION.  663 

it>-.  tympanites,  vomiting,  and  constipation,  which  vary  accordino-  to 
tlie  extent  and  type  of  the  disease.  It  is  generally  less  difficult  to 
diagnosticate  the  existence  of  the  disease  than  to  ascertain  the 
location  and  nature  of  its  primary  cause. 

An  intelligent  and  s}-stematic  discussion  of  acute  peritonitis 
must  be  based  necessarily  on  a  rational  classification.  A  great  deal 
that  has  been  said  and  written  on  this  subject  from  the  distant  past 
until  the  present  time  is  worthless  from  a  scientific  as  well  as  a 
practical  standpoint,  owing  to  a  lack  of  a  proper  classification.  The 
ordinary  terms  used  to  designate  the  different  forms  of  peritonitis 
are  differently  interpreted  and  applied  b\'  pathologists  and  clinicians. 
Acute  inflammation  of  the  peritoneum  is  produced  by  so  many  dif- 
ferent causes  and  assumes  such  varied  clinical  aspects  that  it  is  ex- 
tremely difficult  to  formulate  a  satisfactory  classification.  A  dis- 
cussion of  the  etiology,  differential  diagnosis,  prognosis,  and  treat- 
ment of  acute  peritonitis  except  upon  the  basis  of  a  clear  and  com- 
prehensive classification  is  fruitless,  misleading,  and  usually  results 
in  the  deduction  of  erroneous  and  often  dangerous  conclusions. 
The  classification  should  include  the  anatomy,  pathology,  and  eti- 
ology of  the  disease  to  be  of  \-alue  in  rendering  a  correct  diagnosis, 
a  reliable  prognosis,  and  in  enabling  the  physician  and  surg^eon  to 
advise  and  apply  effective  therapeutic  measures.  It  is  especiall}-  im- 
portant in  the  discussion  of  the  surgical  treatment  of  peritonitis  to 
make  a  clear  distinction  between  the  different  clinical  forms  of  peri- 
tonitis, with  a  view  to  pointing  out  the  limitation  of  purel}-  medical 
treatment  and  the  legitimate  scope  of  surgical  inter\'ention. 

I.  Anatomic  Classification. — An  accurate  anatomic  diagnosis 
is  necessary  for  the  purpose  of  locating  the  inflammatory  process 
correctly  or  to  trace  the  connection  between  it  and  the  organ  pri- 
marily the  seat  of  infection.  During  the  beginning  of  the  attack 
and  in  ca.ses  of  localized  peritonitis  the  inflammation  can  usually  be 
located  without  much  difficult}-,  while  the  reverse  is  often  the  case 
after  the  disea.se  has  become  diffuse.  The  inflammation  may  com- 
mence and  spread  from  either  surface  of  the  serous  membrane,  \is- 
ceral  or  parietal. 

(a)  Ectoperitonitis. — An  inflammation  of  the  attached  side  of 
the  peritoneum  is  called  ectoperitonitis.  As  compared  with  inflam- 
mation of  the  serous  surface,  this  inflammation  of  the  subendothelial 
va.scular  connective  ti.ssue  is  characterized  clinicall>-  and  pathologi- 
cally by  intrinsic  tendencies  to  limitation  of  the  inflammatory 
process.  The  mechanical  and  anatomic  conditions  for  the  diffusion 
of  the  infection  are  less  favorable  than  when  the  free  surface  of  the 
membrane  is  affected.  Ectoperitonitis,  however,  in  certain  localities 
may  become  quite  diffuse,  as  when  the  cavum  Retzii  (Wm.  Gruber) 
or  the  retrf)pLritoneal  space  on  either  side  of  the  spinal  column  is 
the  .seat  of  a  suppurative  inflammation.  In  the  latter  locality  a 
paranephric  or  spondylitic  abscess  is  often  the  cause  of  an  extended 
ectoj)eritonitis,  the  extent  of  the  disease  corresponding  with  the  size 


664  PERITONITIS. 

of  the  subperitoneal  abscess.  In  infected  wounds  of  any  part  of 
the  abdominal  wall  in  which  the  peritoneum  is  exposed,  but  not  per- 
forated, the  primary  ectoperitonitis  is  occasionally  followed  by  the 
extension  of  the  infection  to  the  serous  surface  through  the  lym- 
phatics, or  the  direct  extension  of  the  infective  process  through  the 
tissues  until  it  reaches  the  endothelial  lining.  Peritonitis  of  a  vis- 
ceral origin  is  always  preceded  by  ectoperitonitis,  Avhether  the  in- 
fection reaches  the  peritoneal  cavity  through  a  perforation  or  by 
progressive  extension  of  the  infection  from  the  primary  focus  through 
the  tissues  until  it  reaches  the  free  peritoneal  surface. 

(b)  Endoperitonitis. — What  is  usually  spoken  of  and  described 
as  peritonitis  is  an  inflammation  of  the  serous  surface  of  the  perito- 
neum, which,  anatomically  speaking,  is  an  endoperitonitis.  Endo- 
peritonitis not  infrequently  leads  to  ectoperitonitis  and  the  formation 
of  subserous  abscesses.  In  inflammation  of  the  serous  coat  of  the 
intestine  the  peritoneum  is  always 'loosened  and  frequently  exten- 
sively detached  by  the  secondary  ectoperitonitis. 

(c)  Parietal  Peritonitis. — Inflammation  of  the  serous  lining  of 
the  peritoneal  cavity  is  called  parietal  peritonitis.  It  may  occur  as 
a  primary  affection  in  penetrating  wounds  of  the  abdomen,  but 
more  frequently  it  is  met  with  as  a  secondary  disease  in  conse- 
quence of  the  extension  of  an  infection  from  one  of  the  abdominal 
or  pelvic  viscera,  or  perforation  into  the  peritoneal  cavity  of  a  vis- 
ceral ulcer  or  a  subserous  or  visceral  abscess.  Visceral  peritonitis 
is  always  associated  with  parietal  peritonitis,  and  parietal  peritonitis 
is  absent  in  the  visceral  peritonitis  only  when  the  inflammation 
remains  limited  and  the  parietal  peritoneum  is  protected  against 
infection  by  plastic  exudations  or  interposition  of  one  of  the  ab- 
dominal organs.  In  the  female  parietal  peritonitis  of  the  pelvic 
floor  usually  follows  in  the  course  of  an  extension  of  an  infective 
process  from  the  internal  genital  organs  through  the  lymphatics, 
rupture  of  a  visceral  or  connective-tissue  abscess  into  the  perito- 
neal cavity,  or  leakage  of  septic  material  from  the  Fallopian  tubes. 

(d)  Visceral  Peritonitis. — Inflammation  of  the  peritoneal  in- 
vestment of  any  of  the  abdominal  or  pelvic  organs  is  known  as 
visceral  peritonitis.  The  inflammatory  process  is  seldom  limited  to 
a  single  organ,  as  during  the  course  of  the  disease  adjacent  organs 
or  the  parietal  peritoneum  will  surely  become  involved.  In  general 
peritonitis  the  whole  peritoneal  sac  and  the  serous  covering  of  all 
the  abdominal  organs  are  affected.  The  nomenclature  of  visceral 
peritonitis  is  a  lengthy  one,  as  it  includes  all  the  abdominal  and 
pelvic  organs  that,  when  the  seat  of  a  suppurative  inflammation, 
may  become  the  primary  starting-point  of  an  attack  of  localized 
or  diffuse  peritonitis.  The  meseniery  and  omentum  are  modified 
anatomic  forms  of  the  peritoneum,  and  when  the  seat  of  inflamma- 
tion, we  speak  of  mesenteritis  and  epiploitis.  Peritonitis  involving 
the  serous  covering  of  any  abdominal  organ,  and  arising  in  conse- 
quence of  an  inflammation  of  the  organ   that  it  invests,  is  desig- 


TRAUMATIC    PERITONITIS.  66$ 

nated  by  the  prefix  peri-,  and  the  noun  used  to  indicate  the  organ 
primarily  affected  in  a  state  of  inflammation  which  has  given  rise  to 
the  following  terms  :  perigastritis,  perienteritis,  perityphlitis,  peri- 
appendicitis, pericolitis,  perihepatitis,  perisplenitis,  pericystitis,  peri- 
salpingitis, and  perioophoritis. 

(e)  Pelvic  Peritonitis. — Inflammation  limited  to  the  peritoneal 
lining  of  the  pelvis  and  its  contents  is  known  clinically  and  anatom- 
ically as  pelvic  peritonitis.  It  is  an  affection  almost  entirely  limited 
to  the  female  sex,  and  in  the  majority  of  cases  is  caused  by  exten- 
sion of  gonorrheal  infection  from  the  Fallopian  tubes,  or  a  mild 
form  of  pyogenic  infection  from  the  uterus,  its  adnexa,  or  the  con- 
nective tissue  of  the  parametrium. 

(f)  Diaphragmatic  Peritonitis. — Inflammation  of  the  under 
surface  of  the  diaphragm  is  described  as  diaphragmatic  peritonitis, 
and  when  it  assumes  a  suppurative  type  and  remains  limited,  leads 
to  the  formation  of  subdiaphragmatic  abscess.  This  acute  localized 
form  of  peritonitis  is  usually  secondary  to  suppurative  affections  of 
the  liver  and  gall-bladder  and  perforating  ulcers  of  the  stomach 
and  duodenum. 

2.  Etiologic  Classification. — The  classification  of  peritonitis 
upon  an  etiologic  basis  is  of  the  greatest  importance  and  practical 
value.  The  nature  of  the  exciting  cause  frequently  determines  the 
anatomic  and  pathologic  varieties.  It  likewise  has  a  strong  bearing 
upon  the  prognosis,  and  often  furnishes  positive  indications  as  to  the 
methods  of  treatment  that  should  be  adopted.  Peritonitis,  like 
every  other  inflammatory  affection,  is  always  the  result  of  infection 
with  pathogenic  microbes,  usually  of  the  pyogenic  variety.  The 
etiology  must  consider  the  different  avenues  through  which  the 
microbes  find  their  way  into  the  peritoneal  cavity. 

(a)  Traumatic  Peritonitis. — Primary  peritonitis  has  usually  a 
traumatic  origin — that  is,  the  injury  establishes,  between  the  peri- 
toneal cavity  and  the  surface  of  the  body  or  some  of  the  hollow 
abdominal  or  pelvic  organs,  a  communication  through  which  pyo- 
genic bacteria  enter  in  sufficient  number  and  of  adequate  virulence 
to  cause  an  acute  inflammation.  Traumatic  peritonitis  is  most  fre- 
quently caused  by  [)enetrating  wounds  of  the  abdominal  wall,  the 
uterus,  bladder,  rectum,  and  lower  portion  of  the  esophagus.  In 
some  cases  the  penetrating  wounds  of  the  chest  extend  into  the 
abdominal  cavity  through  the  diaphragm.  Contusions  and  lacera- 
tions of  the  abdominal  organs  often  cause  peritonitis  by  extravasa- 
tion of  the  secretions  or  excretions  of  the  injured  organ.  Not 
infrequently  the  injury  is  followed  by  a  circumscribed  suppurative 
inflammation  in  the  injured  organ,  which  later  i.s  followed  by  diffuse 
peritonitis  from  perforation  of  an  abscess  or  the  injured  wall  of  any 
part  of  the  gastro-intestinal  canal,  in  which  case  the  peritonitis 
follows  as  a  secondary  affection. 

(b)  Idiopathic  Peritonitis. — The  occurrence  of  peritonitis  with- 
out an  antecedent  injury  or  supi)urative  lesion  is  doubted  by  many. 


666  PERITONITIS. 

It  is  an  exceedingly  rare  affection,  since  pathologists  and  surgeons 
have  brought,  by  their  investigations  and  observations,  the  perito- 
neal inflammations  with  few  exceptions  into  connection  w^ith  neigh- 
boring or  distant  primary  suppurative  lesions.  It  is  certainly  much 
rarer  than  primary  inflammation  of  the  pleura  and  pericardium  as 
an  isolated  affection.  It  is  too  early  to  deny  in  toto  the  existence 
of  so-called  idiopathic  peritonitis,  but  future  bacteriologic  examina- 
tions of  the  inflammatory  product  will  no  doubt  reveal  a  microbic 
cause  in  all  such  cases.  Ley  den  found  diplococci  and  streptococci 
in  the  inflammatory  exudate  in  a  case  of  primary  peritonitis.  As  an 
isolated  affection  peritonitis  is  found  most  frequently  in  females  dur- 
ing or  soon  after  menstruation  ;  it  is  probable  that  the  pyogenic 
bacteria  multiply  in  the  blood  that  accumulates  in  the  uterus,  and 
reach  the  peritoneal  cavity  through  the  Fallopian  tubes.  It  is  said 
to  have  occurred  in  consequence  of  exposure  to  cold,  and  is  then 
known  as  rheumatic  peritonitis.  Occasionally  it  has  been  observed 
as  one  of  the  remote  manifestations  of  Bright's  disease,  pyemia,  and 
the  acute  eruptive  fevers. 

(c)  Perforative  Peritonitis. — Perforation  of  an  ulcer  of  any  part 
of  the  gastro-intestinal  canal,  or  of  an  abscess  of  any  of  the  abdom- 
inal or  pelvic  organs,  or  of  the  abdominal  wall  into  the  peritoneal 
cavity,  is  by  far  the  most  frequent  cause  of  acute  peritonitis.  Two 
important  and  frequent  causes  are  appendicitis  and  suppurative  sal- 
pingitis. If  localized  inflammation  develops  over  the  ulcer  or  abscess 
before  perforation  takes  place,  the  general  peritoneal  cavity  is  often 
protected  by  firm  adhesions  before  the  accident  occurs,  and  the 
peritonitis  remains  circumscribed.  If,  however,  the  contents  of  the 
gastro-intestinal  canal  or  the  abscess  cavity  reach  the  free  perito- 
neal cavity,  a  diffuse  septic  peritonitis  sets  in,  which  usually  destroys 
life  within  from  twelve  to  seventy-two  hours,  unless  prompt  surgical 
treatment  is  resorted  to.  Experimental  research,  as  well  as  clinical 
observation,  has  demonstrated  that  the  intestinal  wall,  when  paretic 
or  gangrenous,  becomes  permeable  to  the  microbes  contained  in  the 
intestinal  canal.  In  many  cases  of  intestinal  obstruction,  acute  and 
chronic,  death  results  from  septic  peritonitis  after  the  intestine  has 
become  paretic  or  gangrenous. 

(d)  Metastatic  Peritonitis. — This  form  of  peritonitis  occurs, 
like  other  metastatic  affections,  in  connection  with  a  suppurative  or 
infectious  process  anatomically  disconnected  from  the  peritoneum. 
It  is  rarer  than  metastatic  pleuritis,  and  is  seldom  seen  except  as  a 
pyemic  lesion.  In  very  rare  cases  it  develops  in  the  course  of  many 
of  the  acute  infectious  diseases,  as  scarlatina,  smallpox,  erysipelas, 
rubeola,  and  even  varicella.  It  also  occurs  frequently  in  the  course 
of  septicemia  and  pyemia.  Andral  and  Desplatz  have  seen  it  occur 
during  attacks  of  acute  articular  rheumatism.  It  has  also  been  ob- 
served in  scorbutic  subjects  and  in  patients  suffering  from  valvular 
disease  of  the  heart. 

(e)  Puerperal  Peritonitis. — Peritonitis  occurring  in  connection 


DIFFUSE    SEPTIC    PERITONITIS.  66/ 

with  septic  diseases  of  the  puerperal  uterus  has  for  a  long  time 
been  known  as  puerperal  peritonitis.  The  infection  may  extend  from 
the  endometrium  through  the  Fallopian  tubes,  or  may  follow  the 
lymph-channels  or  the  thrombosed  infected  uterine  veins.  Infec- 
tion through  the  Ij'mphatics  usually  results  in  rapidly  fatal  diffuse 
septic  peritonitis,  while  in  thrombophlebitis  there  is  a  greater  ten- 
dency to  localization  unless  the  thrombi  disintegrate  and  cause  em- 
bolism and  pyemia. 

(f)  Peritonitis  Infantum. — Peritonitis  attacks  most  frequently 
infants,  children,  young  adults,  and  women  during  the  child-bear- 
ing period  of  life,  but  no  age  is  exempt. 

(g)  Fetal  and  Intra=uterine  Peritonitis. — If  the  disease  attacks, 
as  it  occasionally  does,  the  fetus  in  iitcn\  it  often  results  in  death 
before  or  soon  after  the  birth  of  the  child  ;  most  frequently  death 
ensues  during  the  seventh  to  the  ninth  month  of  gestation.  Pre- 
natal peritonitis  is  frequently  associated  with  syphilis.  In  most 
cases  the  disease  is  detected  only  at  the  postmortem  ;  in  others 
death,  if  the  child  is  born  alive,  is  preceded  by  meteorismus, 
icterus,  and  edema  of  the  legs. 

(h)  Peritonitis  Neonatorum. — Infection  takes  place  during  the 
first  few  weeks  after  birth  through  the  imperfectly  healed  ulcerating 
umbilicus.  It  has  been  met  with  most  frequently  in  children  whose 
mothers  were  afflicted  with  puerperal  fever.  Besides  peritonitis, 
symptoms  of  pyemia  appear. 

3.  Pathologic  Classification. — The  pathologic  conditions  that 
characterize  the  different  varieties  of  peritonitis  must  necessarily  be 
considered  in  classifying  this  disease.  The  pathologic  classification 
is  based  almost  entirely  upon  the  gross  and  microscopic  appearances 
of  the  inflammatory  exudation  and  transudation. 

(a)  Diffuse  Septic  Peritonitis. — Every  acute  peritonitis  is  septic 
in  so  far  that  phlogistic  substances  reach  the  general  circulation  from 
the  inflammatory  lesion,  and  in  that  frequently  the  inflammation 
terminates  in  suppuration  ;  but  the  term  septic  peritonitis  should  be 
limited  to  those  cases  of  diffuse  septic  inflammation  in  which,  as  a 
rule,  death  occurs  in  a  few  days,  and  before  any  gross  pathologic 
conditions  have  had  time  to  develop.  It  is  a  disease  that  is  almost 
uniformly  fatal  with  or  without  operative  treatment,  the  patients 
dying  from  the  effects  of  progressive  sepsis.  The  claim  of  opera- 
tors to  have  cured  such  cases  by  laparotomy  must  be  accepted  with 
a  good  deal  of  allowance.  The  microbes  that  produce  this  form  of 
peritonitis  are  tho.sc  that  follow  the  lymph-spaces,  and  are  rapidly 
diffused  not  only  over  the  entire  peritoneal  suiface,  parietal  and  vis- 
ceral, but  also  through  the  subserous  lymphatic  channels.  The 
disease  is  observed  most  frequently  after  perforation,  into  the  free 
peritoneal  cavity,  of  an  abscess  containing  septic  pus,  rupture  or  per- 
foration of  any  of  the  abdominal  or  pelvic  viscera  containing  septic 
material,  gunshot  or  stab  wounds  of  the  abdomen  with  visceral 
injury  of  the  gastro-intestinal  canal,  and   occasionally  as  the  result 


668  PERITONITIS. 

of  infection  during  laparotomy.  The  gravest  form  of  puerperal 
fever  is  a  diffuse  septic  peritonitis.  The  subjects  of  this  variety  of 
peritonitis  die  so  soon  after  the  beginning  of  the  disease  that  at  the 
postmortem,  or,  if  the  abdomen  is  opened  during  hfe,  at  the  opera- 
tion, no  gross  tissue  changes  are  discovered — beyond  a  shghtly 
increased  vascularity,  nothing  is  found  to  indicate  the  existence  of 
peritonitis.  The  septic  material,  formed  in  large  quantities  and  of 
great  virulence,  is  rapidly  absorbed  by  the  stomata  of  the  under 
surface  of  the  diaphragm,  discovered  and  described  by  von  Reck- 
linghausen. 

(b)  Putrid  Peritonitis. — The  inflammatory  product  in  this  form 
of  peritonitis  is  a  scanty  brown  or  reddish-brown  fetid  fluid.  It 
occurs  most  frequently  in  connection  with  grave  forms  of  puerperal 
metritis.  It  is  usually  associated  with  more  or  less  gangrene  or 
ulceration  of  the  organ  or  parts  primarily  affected,  as  uterus,  intes- 
tine, or  abdominal  wall. 

(c)  Hemorrhagic  Peritonitis. — The  ascites  which  so  frequently 
develops  in  consequence  of  malignant  or  tubercular  disease  of  the 
peritoneum  is  composed  of  serum,  frequently  stained  with  blood, 
but  in  acute  peritonitis  the  transudate  is  occasionally  hemorrhagic 
by  the  tearing  of  vascular  adhesions,  and  rhexis  is  also  observed  in 
persons  suffering  from  peritonitis  who  are  greatly  debilitated,  scor- 
butic, or  intemperate,  and  occasionally  when  peritonitis  occurs  in 
patients  suffering  from  typhoid  fever.  It  is  met  with  most  frequently 
in  the  pelvis,  upon  the  posterior  surface  of  the  uterus  and  vagina, 
and,  in  men,  behind  the  bladder.  The  inflammatory  product  appears 
in  the  form  of  brown  patches,  composed  of  delicate  and  very  vascu- 
lar villi.  These  villi,  from  their  unfavorable  location,  are  subjected 
to  frequent  mechanical  disturbances,  and  when  injured  bleed,  giving 
rise  to  the  so-called  retro-uterine  or  retrovesical  hematocele. 

(d)  Suppurative  Peritonitis. — Suppurative  peritonitis — that  is, 
an  inflammation  of  the  peritoneum  which  results  in  the  formation  of 
pus — is  always  more  or  less  circumscribed.  This  form  of  periton- 
itis is  the  most  frequent,  and  is  generally  associated  with  more  or 
less  fibrinoplastic  exudation.  The  pus  is  serous,  seropurulent,  or 
may  reach  the  consistence  of  cream,  when  it  is  usually  of  a  yellow 
Color.  The  accumulation  of  pus  may  be  so  large  that  upon  open- 
ing the  abdominal  cavity  it  may  appear  as  though  the  entire  perito- 
neal cavity  and  all  the  organs  contained  within  were  implicated ; 
but  a  careful  examination  will  almost  always  reveal  the  fact  that  a 
large  part  of  the  peritoneal  cavity  and  many  of  the  organs  were  shut 
out  from  the  inflammatory  process  by  plastic  adhesions.  Suppura- 
tive peritonitis  must,  therefore,  be  regarded  from  a  practical  stand- 
point as  a  circumscribed  inflammation.  The  appearance  and  char- 
acter of  the  pus  are  often  greatly  modified  by  the  admixture  of  an 
extravasation  accompanying  the  perforative  lesion  that  produces  the 
peritonitis.  If  the  pus  is  thin  and  serous,  we  speak  of  a  seroptirulent 
peritonitis — it  is  a  serous  peritonitis  with  the  formation  of  pus  in 


FIBRIXOPLASTIC    PERITONITIS.  669 

sufficient  quantity  to  render  the  serum  more  or  less  turbid.  This 
subvariety  of  suppurative  peritonitis  is,  without  exception,  in  com- 
bination with  fibrinous  exudations  that  tend  to  Hniit  the  extension 
of  the  infective  process.  Sedimentation  of  the  soHd  constituents 
takes  place,  so  that  the  fluid  contains  more  of  the  solid  constituents 
in  the  most  dependent  portion  of  the  affected  district. 

(e)  Serous  Peritonitis. — Independently  of  malignant  and  tuber- 
cular disease  of  the  peritoneum,  circumscribed  hydrops  of  the  peri- 
toneal cavity  is  caused  by  a  very  mild  form  of  peritonitis,  the  pus- 
microbes  present  not  being  sufficient  in  number  to  produce  pus. 
Patients  usually  recover  rapidly  from  this  form  of  peritonitis.  The 
slight  alterations  of  the  peritoneum  produced  by  the  inflammatory 
process  do  not  interfere  with  the  transudation  of  serum,  and  resorp- 
tion is  effected  as  soon  as  the  inflammation  subsides  and  the  normal 
absorptive  function  of  the  peritoneum  is  restored.  Serous  periton- 
itis is  usually  more  or  less  complicated  by  fibrinous  peritonitis,  as 
fragments  of  fibrin  are  often  found  suspended  in  the  fluid.  The 
serum  is  generally  somewhat  turbid,  not  transparent,  and  gra^ish- 
yellow  or  reddish  in  color.  So  long  as  the  fluid  is  limited  in  quan- 
tit\-  it  gravitates  toward  the  most  dependent  parts  of  the  abdominal 
cavity  in  the  small  pelvis  ;  when  more  copious,  it  reaches  the  upper 
portions  of  the  peritoneal  cavity,  and  seeks  first  the  depression  on 
each  side  of  the  spinal  column. 

(f)  Fibrinoplastic  Peritonitis. — Peritonitis  in  which  plastic  ex- 
udations are  formed  and  pus  is  absent  or  scanty  is  called  fibrino- 
plastic peritonitis.  Exudative  peritonitis  and  peritonitis  adJiesiva  seu 
sicca  have  been  used  as  synonymous  terms  for  this  variety  of  periton- 
itis. It  is  usually  a  secondary  process,  following  a  primary  affec- 
tion of  one  of  the  abdominal  or  pelvic  organs,  and  denotes  a  com- 
paratively mild  form  of  infection,  the  extension  of  which  becomes 
limited  by  firm  adhesions.  The  inflammation  results  in  a  plastic 
exudation  with  little  or  no  effusion.  The  character  of  the  exudate 
depends  on  the  intensity  and  quality  of  the  bacterial  cause.  The 
exudation  is  often  so  copious  that  it  has  been  mistaken  for  malig- 
nant disease.  Goldberg  reports  two  such  cases.  The  symptoms 
were  marked  cachexia,  ascites,  uncontrollable  diarrhea,  and  ai)par- 
ent  tumor  deep  in  the  abdomen.  The  distinguishing  features  of 
this  form  of  peritonitis  from  abdominal  tumor  are  the  less  circum- 
scribed outhne,  the  less  resistance  offered,  the  more  regular  surface, 
and  the  fact  that  the  ascitic  fluid  is  not  bloody,  but  serous  or  sero- 
purulent.  The  exudation  in  the  course  of  time  contracts  and  results 
in  strong  bands  of  adhesion,  which  frequently  flex  and  distort  the 
organs  to  which  they  are  attached,  thus  giving  rise  to  another  term 
— peritonitis  deformans. 

4.  Bacteriologic  Classification. — As  tlu:  essential  causes  of 
jjcritonitis  are  always  the  presence  and  action  of  pathogenic  mi- 
crobes anrl  their  toxins  upon  the  peritoneum,  and  as  the  character 
of  the  inflammatory  process  is   largely  influenced   by  the  kind  of 


6/0  PERITONITIS. 

microbes  that  produced  the  infection,  a  bacteriologic  classification  is 
of  the  greatest  scientific  and  practical  importance.  All  pus-microbes 
present  in  sufficient  number  and  virulence  in  the  peritoneal  cavity 
can  produce  peritonitis.  Experiments  as  well  as  clinical  observation 
have  shown,  however,  that  their  action  is  enhanced  by  local  con- 
ditions that  favor  their  growth  and  reproduction.  Injuries  or  ante- 
cedent lesions  of  the  peritoneum  and  the  presence  of  putrescible 
substances  furnish  such  predisposing  and  exciting  conditions. 

(a)  Streptococcus  Infection. — The  streptococcus  pyogenes  is 
the  microbe  that  is  most  frequently  found  in  the  tissues  in  cases  of 
diffuse  septic  peritonitis.  The  infection  spreads  so  rapidly  over  the 
peritoneal  surface  and  through  the  subserous  lymphatics  that  death, 
as  a  rule,  occurs  from  septic  intoxication  before  a  sufficient  length 
of  time  has  elapsed  for  any  gross  pathologic  conditions  to  form. 
Absence  of  fibrinous  exudate  and  effusion  is  the  most  striking  nega- 
tive finding  at  operations  and  necropsies.  Streptococcus  infection 
is  the  immediate  cause  of  the  most  fatal  form  of  puerperal  peri- 
tonitis. Frankel  has  found  the  streptococcus  pyogenes  in  a  great 
variety  of  puerperal  diseases,  especially  in  cases  in  which  the  local 
affection  implicated  the  lymphatic  vessels.  In  such  cases  the 
microbes  found  entrance  into  the  pelvic  tissues  from  abrasions  of 
the  vagina  or  uterus,  and,  by  extension  of  the  inflammatory  pro- 
cess, the  broad  ligaments  and  the  peritoneum  are  successively 
reached.  After  the  peritoneum  has  once  been  infected,  rapid  diffu- 
sion takes  place,  and  finally  the  diaphragm  and  pleurae  are  impli- 
cated in  the  same  process,  and  the  patient  dies  from  the  effects  of 
progressive  sepsis. 

(b)  Staphylococcus  Infection. — In  peritonitis  caused  by  staphy- 
lococcus infection  the  intrinsic  tendency  to  localization  of  the  dis- 
ease is  more  marked — the  inflammation  results  more  often  in  cir- 
cumscribed suppuration  and  limitation  of  the  infective  process  by 
copious  fibrinoplastic  exudations.  As  a  rule,  the  inflammation 
terminates  in  the  formation  of  thick,  cream-colored  pus.  Different 
forms  of  staphylococci  are  often  seen  in  the  same  inflammatory 
product. 

(c)  Pneumococcus  Infection. — It  is  now  well  known  that  pneu- 
monia is  produced  by  different  microbes,  but  the  diplococcus  is 
found  in  about  80  per  cent,  of  all  cases.  It  is  this  microbe  that 
occasionally  is  found  as  the  bacteriologic  cause  of  acute  suppura- 
tive peritonitis.  Weichselbaum  has  found  the  diplococcus  of 
pneumonia  unaccompanied  by  any  other  micro-organism  in  three 
cases  of  peritonitis.  In  one  case  the  peritonitis  and  acute  pneu- 
monia occurred  simultaneously  ;  in  the  other,  double  pleuritis  fol- 
lowed the  peritonitis  ;  but  in  the  last  case  the  peritonitis  was  un- 
doubtedly primary,  and,  in  the  absence  of  any  other  microbes  in 
the  inflammatory  product,  must  have  been  caused  solely  by  the 
diplococcus  of  pneumonia. 

Etheridge  has  described  three    cases  of   abscess  of  the  ovary 


TUBERCULAR    INFECTION.  6/1 

complicated  b}'  plastic  peritonitis,  in  the  contents  of  which  the 
diplococcus  alone  was  found.  Le  Gendre  reports  a  case  of  peri- 
tonitis in  a  girl  of  eighteen  years  ;  the  pus  was  yellowish-green, 
lumpy,  and  of  a  fibrinous  consistence,  and  contained  a  pure  culture 
of  the  pneumococcus.  The  author  found  altogether  eleven  cases 
recorded,  eight  of  which  had  been  fatal.  Another  case  is  reported 
by  Veillon.  The  suppuration  caused  by  pneumococcus  infection 
is  almost  invariably  attended  by  copious  fibrinoplastic  exudation. 

(d)  Bacillus  Coli  Communis  Infection. — The  bacillus  coli  com- 
munis, a  microbe  that  constantly  infests  the  intestinal  canal,  is,  in  a 
fair  percentage  of  cases,  the  bacteriologic  cause  of  acute  peritonitis. 
This  microbe  possesses  pyogenic  properties,  and  in  intestinal  paresis 
and  perforations  escapes  into  the  peritoneal  cavity  and  produces 
usually  a  pathologically  mixed  form  of  peritonitis — that  is,  sup- 
purative and  fibrinoplastic  peritonitis.  Of  thirty-one  cases  of  peri- 
tonitis examined  by  Frankel,  this  microbe  Was  found  in  nine.  In 
eleven  cases,  seven  gave  mixed  cultures,  and  in  three  of  these  the 
colon  bacillus  predominated.  The  same  author  has  shown  that  pure 
cultures  injected  into  the  abdominal  cavity  of  rabbits  cause  tj-pical 
peritonitis. 

(e)  Gonococcus  Infection. — In  the  peritoneal  cavity  the  gono- 
coccus  produces  a  plastic  peritonitis  and  sometimes  localized  sup- 
puration. Salpingoperitonitis  and  more  diffuse  pelvic  peritonitis 
are  most  frequently  caused  by  gonococcus  infection.  "  The  proper 
character  and  results  of  the  pathogenous  activity  of  the  gonorrheic 
microbes  are,  therefore,  seen  pure  and  unadulterated  in  the  tubes. 
They  cause  purulent  inflammation  of  the  mucous  membrane,  but 
the  surrounding  connective  tissue  remains  free  from  them.  The 
gonorrheic  tubal  pus  is  evacuated  into  the  peritoneum  ;  and, 
whereas  in  other  conditions  the  bursting  of  an  abscess  into  the 
abdominal  cavity  is  followed  by  the  gravest  consequences,  in  this 
case  the  whole  process  terminates  with  a  circumscribed  inflamma- 
tion encapsulating  the  exuded  pus.  The  cause  of  this  difference  is 
the  varying  pathogenic  value  of  the  organisms  that  are  contained 
in  the  pus,  A  puerperal  pelvic  cellulitic  abscess  bursting  into  the 
peritoneum  causes  general  peritonitis,  because  it  contains  pyogenic 
streptococci,  which  rapidly  multiply  in  serous  cavities  and  are  capa- 
ble of  exerting  the  most  deleterious  effects.  Gonorrheal  tubal  j^us 
can  not  do  this  ;  its  microbes  do  not  find  in  the  peritoneum  con- 
ditions for  their  increase  ;  the  ])us,  therefore,  acts  as  an  aseptic 
foreign  body,  becomes  encapsulated,  and  is  finalh'  absorbed  " 
(Sinclair). 

(f)  Tubercular  Infection. — The  rapid  diffusion  of  the  tubercle 
bacillus  in  the  perit(jneal  cavity,  tlirough  either  the  circulation  or 
by  rupture  of  a  tubercular  abscess  into  the  peritoneal  cavity,  or  by 
extension  from  a  tubercular  salpingitis  or  a  tubercular  intestinal 
ulcer,  occasionally  gives  rise  to  a  form  of  acute  peritonitis  character- 
ized as  such,  in  a  modified  way,  by  the  clinical  manifestations  that 


6/2  PERITONITIS. 

accompany  it.  According  to  the  intensity  of  the  infection  or  the 
degree  of  susceptibihty  of  the  patient  to  the  action  of  the  tubercle 
bacillus,  the  disease  assumes  one  of  the  following  pathologic  forms  : 
I.  Tubercular  ascites.  2.  Fibrinoplastic  peritonitis.  3.  Adhesive 
peritonitis.  Suppuration  takes  place  only  when  the  tubercular 
product  becomes  the  seat  of  a  secondary  mixed  infection  with  pus- 
microbes. 

5.  Clinical  Classification. — From  a  practical  standpoint  the 
chnical  classification  is  the  most  important.  A  modern  clinical 
classification  must  be  based  on  the  location,  causes,  and  pathologic 
types  of  the  inflammatory  process  as  just  outlined.  Upon  a  correct 
clinical  differentiation  between  the  various  forms  of  peritonitis  as 
seen  at  the  bedside  depends  largely  the  adoption  of  a  rational  course 
of  treatment.  The  recognition  of  the  disease  no  longer  completes 
the  diagnosis  for  the  physician,  much  less  for  the  surgeon.  A 
diagnosis  for  the  careful  physician  and  conscientious  surgeon  must 
include  the  location,  extent,  causation,  and  pathology  of  the  dis- 
ease. From  the  information  gained  from  the  classification  already 
made,  must  be  obtained  the  material  upon  which  to  base  a  clinical 
classification.  Such  classification  should  serve  as  a  guide  in  differ- 
entiating between  the  cases  that  demand  surgical  intervention  and 
the  cases  that  can  be  trusted  to  medical  treatment. 

(a)  Ectoperitonitis. — Abscess  formation  in  the  subperitoneal 
connective  tissue,  as  seen  most  frequently  in  the  pelvis  in  women, 
in  the  cavity  of  Retzius  in  men,  and  in  the  retroperitoneal  space  in 
both  sexes,  is  always  attended  by  inflammation  of  the  outer  sur- 
face of  the  peritoneum,  and  is  not  infrequently  followed  by  extension 
of  the  infection  through  the  lymphatic  spaces  to  the  free  surface, 
and  exposes  the  patients  to  the  risks  of  perforation  of  the  abscess 
into  the  free  peritoneal  cavity,  septic  diffuse  peritonitis,  and  death. 
Such  abscesses  should  be  recognized  and  accurately  located  suf- 
ficiently early  to  prevent  such  serious  complications  by  an  extra- 
peritoneal incision  and  drainage  ;  or,  if  the  abscess  is  of  tubercular 
nature,  by  tapping,  evacuation,  and  iodoformization. 

(b)  Diffuse  Septic  Peritonitis. — This  form  of  peritonitis  is  char- 
acterized clinically  by  the  gravity  of  the  general  symptoms  from  the 
very  incipiency  of.the  disease  ;  pathologically,  by  the  rapid  diffusion 
of  the  infection  over  the  entire  serous  surfaces,  visceral  and  parietal ; 
bacteriologically,  by  the  presence,  in  most  of  the  cases,  of  the  strep- 
tococcus pyogenes  in  the  inflamed  tissues.  Staphylococci,  pneu- 
mococci,  and  the  colon  bacillus  may  also  be  the  causes  of  rapidly 
spreading  diffuse  peritonitis.  This  form  of  peritonitis  usually  fol- 
lows penetrating  wounds  of  the  abdominal  cavity  complicated  by 
visceral  injuries  of  the  gastro-intestinal  canal,  contusion  or  lacera- 
tion of  any  of  the  abdominal  or  pelvic  organs,  in  rupture  of  an 
abscess  or  ulcer  into  the  free  peritoneal  cavity,  or  the  extension  of 
a  septic  lymphangitis  from  any  of  the  abdominal  or  pelvic  organs 
to  the  peritoneum.      Strict  aseptic  precautions  have  succeeded  in 


CIRCUMSCRIBED    PERITONITIS.  67^ 

greatly  reducing,  but  not  entirely  eliminating,  the  danger  from  this 
source  m  all  operations  requiring  opening  of  the  free  peritoneal 
cavity.  In  genume  cases  of  general  septic  peritonitis  surmcal  inter- 
vention IS  usually  powerless  to  prevent  speedy  death  from  toxemia 
while  prompt  surgical  interference  may  cope  successfully  with  the 
amuse  variety. 

(c)  Perforative    Peritonitis.— Perforative    peritonitis   invariably 
occurs  as  a  secondar>^  affection,  usually  in  connection  with  an  ulcer- 
ative or  gangrenous  lesion  of  some  part  of  the  gastro-intestinal  canal 
Perforative  ulcer  of  the  stomach  or  duodenum,  or  typhoid  or  tuber- 
^h.  ^•^^^'!  i         '^r"""'  perforation  or  sloughing  of  the  appendix, 
the  differen    forms  of  intestinal  obstruction,  are  the  most  frequeni 
causes  of  this  well-defined  clinical  form  of  peritonitis.      Perforative 
peritonitis   is   manifested  by  the  sudden   onset  of  the   disease    bv 
diffuse  pam  and  tenderness,  rigid  abdominal  walls,  fever,  vomitin/ 
the    impossibility,    by  inspection,    palpation,    and    auscultation    ?o 
ascertain   intestinal   peristalsis,  this  condition  being  almost  positive 
proof  of  the  presence  of  gas  in  the  free  peritoneal  cavity  or  paresis 
of  the  distended  intestines.      According  to  my  observations,  me- 
teonsmus   peritonei  in  perforative   peritonitis  caused  by  affections 
of  the  appendix  is  rare,  while  I  have  seldom  found  it   absent  in 
perforations   of  any  other  portion   of  the   gastro-intestinal   canal 
According  to  the  number  and  virulence  of  the  microbes  that  find 
their  way  mto  the  peritoneal  cavity  with  the  extravasation   the  re- 
sulting pentonitis  is  either  diffuse  or  more  or  less  circumscribed 
1  he  colon  bacillus  is  invariably  present  in  the  inflammatory  product' 
but  in  addition  streptococci,  staphylococci,  putrefactive  bacilli   the 
typhoid  bacillus,  or  bacillus  of  tuberculosis,  according  to  the  nature 
01  the  primary  infection,  may  also  be  found. 

Perforative  peritonitis  must  be  regarded  and  treated  as  a  strictly 
surgical  disease.  The  primary  lesion  must  be  exposed  and  treated 
as  soon  as  a  diagnosis  can  be  made  and  the  necessary  measures  ap- 
plied to  hmit  the  extension  of  the  infection  and  to  prevent  death 
irom  toxemia 


(d)  C.rcumscribed  Peritonitis.— A  circumscribed  peritonitis  is 
an  inflammation  of  the  peritoneum  during  which  a  greater  or  less 
part  of  the  peritoneal  cavity  becomes  excluded  from  the  onVinal 
source  of  infection   by  the  formation   of  plastic,  visceral    parietal 
or  visceral  and  parietal  adhesions.      The   complexus  of  .symptoms 
vanes  according  to  the  degree  of  virulence  of  the  microbic  cause 
which  only  occasionally  is  overshadowed  by  the  primary  affection' 
1  he  symptoms  appear  suddenly  or  are  preceded  by  those  incident 
to  the  primary  disea.se.      The  severity  of  the  pain  and  the  extent  of 
the  muscular  rigidity  and  tenderness  will  correspond  with  the  ex- 
tent of  the  disease.      The  intensity  of  the  general  symptoms  is  de- 
termined more  by  the  nature  and  virulence  of  the  microbic  cause 
than  the  size  of  the  peritoneal  surface  involved.     The  inflammatory 
focus  may  be  limited  to  a  very  small  space,  or  it  may  involve  the 
4^ 


674 


PERITONITIS. 


greater  portion  of  the  peritoneal  cavity  and  organs  that  it  contains. 
The  chnical  course  and  termination  are  determined  largely  by  the 
nature  and  virulence  of  the  primary  bacterial  cause,  the  anatomic 
location  of  the  primary  starting-point,  and  nature  of  environment. 
If  the  organs  adjacent  to  the  primary  focus  of  infection  are  favor- 
ably located  to  limit  the  process,  diffusion  is  frequently  prevented 
by  the  formation  of  adhesions.  This  is  especially  true  in  cases 
where  the  primary  infection  is  limited  by  the  existence  of  old 
adhesions. 

Localized  peritonitis  may  be  confined  to  the  lesser  peritoneum, 
particularly  in  cases  of  perforating  ulcer  of  the  stomach.  More  fre- 
quently it  is  caused  by  appendicitis  and  cecitis.  A  very  frequent 
cause  of  circumscribed  peritonitis  is  inflammation  about  the  gall- 
bladder, uterus,  Fallopian  tubes,  and  ovaries.  The  localized  form 
of  peritonitis  is  very  often  overlooked  during  life.  It  can  usually 
be  detected  only  if  a  demonstrable  swelling  forms  at  the  seat  of  in- 
flammation. The  mildest  form  of  infection  gives  rise  to  fibrinoplastic 
peritonitis,  which  leaves  temporary  or  permanent  adhesions,  but  ter- 
minates without  pus-formation.  Circumscribed  suppurative  inflam- 
mation is  always  attended  by  fibrinoplastic  peritonitis,  the  products  of 
which  and  the  viscera,  which  it  involves,  form  the  abscess  wall. 
The  microbes  that  produce  most  frequently  fibrinoplastic  peritonitis 
without  suppuration  are  the  gonococcus  and  the  staphylococci. 
Circumscribed  suppurative  peritonitis  is  usually  the  result  of  infec- 
tion with  staphylococci,  bacillus  coli  communis,  and  pneumococci. 
In  fibrinoplastic  peritonitis  surgical  interference  becomes  necessary 
only  when  intestinal  obstruction  is  caused  by  the  adhesions.  In 
circumscribed  suppurative  peritonitis  the  pus  should  be  evacuated 
as  soon  as  the  disease  is  recognized,  and,  if  possible,  by  an  extra- 
peritoneal route. 

(e)  Hematogenous  Peritonitis. — In  very  rare  instances  peri- 
tonitis occurs  without  an  injury  or  discoverable  antecedent  lesion 
of  any  of  the  abdominal  or  pelvic  organs,  and  is  then  described  as 
idiopathic  peritonitis.  As  peritonitis  is  always  caused  by  bacteria 
of  some  kind,  a  peritonitis  that  develops  independently  of  a  local 
source  of  infection  is  the  result  of  an  infection  through  the  blood, 
and  should  be  called  hematogenous  or  metastatic  peritonitis.  It 
has  been  observed  in  connection  with  nephritis,  pyemia,  rheumatic 
arthritis,  and  acute  exanthematous  diseases. 

(f)  Visceral  Peritonitis. — A  localized  peritonitis  that  can  be 
brought  in  direct  etiologic  connection  with  the  organ  primarily 
affected  is  expressed  by  a  compound  word  with  the  prefix  peri-  and 
the  noun  used  to  indicate  the  organ  primarily  affected  in  a  state  of 
inflammation.  Thus  the  anatomic  forms  of  peritonitis  present  them- 
selves :  Perigastritis,  perienteritis,  perityphlitis,  periappendicitis, 
pericolitis,  perihepatitis,  perisplenitis,  pericystitis  (urinary  and  gall- 
bladder), perimetritis,  perisalpingitis,  and  perioophoritis. 

As  the  mesentery  and  omentum  are  only  duplications  of  the 


CHRONIC    PERITONITIS.  675 

peritoneum,  we  have  to  add  to  the  foregoing  anatomic  forms  mesen- 
teritis  and  epiploitis. 

(g)  Pelvic  Peritonitis. — Pelvic  peritonitis  is  seldom  met  with  in 
the  male.  It  is  a  form  of  peritonitis  in  which  the  female  pelvic 
organs  are  the  primary  starting-point  of  infection,  with  extension 
to  the  peritoneum,  through  either  the  Fallopian  tubes  or  the  lym- 
phatics of  the  uterus  or  its  adnexa.  It  is  caused  most  frequently 
by  gonorrheal  or  puerperal  infection,  or  develops  after  instrumental 
examination  of  the  interior  of  the  uterus  or  operations  upon  this 
organ. 

(h)  Puerperal  Peritonitis. — By  the  term  puerperal  peritonitis 
is  understood  a  progressive  inflammation  of  the  peritoneum  oc- 
curring in  consequence  of  an  extension  of  an  infection  from  any 
part  of  the  genital  tract  in  puerperal  women  after  delivery  or  abor- 
tion. The  infection  usually  takes  place  through  the  lymphatics, 
and  in  the  majority  of  cases  terminates  in  diffuse  septic  peritonitis. 

(i)  Subdiaptiragmatic  Peritonitis. — A  peritonitis  limited  to  the 
under  surface  of  the  diaphragm  and  any  of  the  adjacent  organs  is 
called  subdiaphragmatic  peritonitis.  If  the  inflammation  remains 
limited  and  life  is  sufficiently  prolonged,  it  usually  terminates  in 
the  formation  of  a  subdiaphragmatic  abscess. 

(J)  Chronic  Peritonitis. — With  few  exceptions  chronic  peri- 
tonitis is  tubercular  peritonitis.  It  is  noted  clinically  by  its  insidious 
onset,  its  slow  course,  the  comparative  mildness  of  the  inflam- 
matory .symptoms,  pain,  and  tenderness,  and  the  absence  of  or  late 
pus-formation.  It  occurs  much  more  frequently  in  the  female  than 
in  the  male,  as  the  Fallopian  tubes  are  the  most  frequent  starting- 
point  of  the  peritoneal  infection.  In  the  male,  extension  of  the 
tubercular  infection  from  the  prostate  and  vesiculae  seminales  occa- 
sionally takes  place,  but  more  frequently  the  primary  source  of 
infection  is  to  be  found  in  the  intestinal  canal.  The  disease  ap- 
pears as  either  a  diffuse  or  localized  affection.  Caseation  of  the 
tubercular  product  takes  place  late  or  is  entirely  wanting.  Patho- 
logically, it  presents  itself  either  as  a  dry  process,  in  which  case  the 
exudate  causes  firm  and  extensive  adhesions,  or  a  free  transudation 
accompanies  the  inflammatory  process  and  results  in  a  diffuse  or 
circumscribed  hydrops.  In  the  latter  case  the  localized  ascites  is 
walled  off  by  fibrinous  exudates  and  adherent  abdominal  organs. 
A  slight  evening  rise  in  temperature,  progressive  marasmus,  and 
the  exi.stence  of  tuberculosis  in  other  organs  are  conditions  that 
would  naturally  arouse  suspicion  of  the  tubercular  nature  of  the 
peritoneal  affection.  /Xbdominal  section  and  drainage  have  accom- 
plished the  most  in  arresting  the  disease  and  in  restoring  health.  I 
have  confidence  in  tapping  followed  by  the  injection  of  a  10  percent, 
iodoform  glycerin  emulsion.  The  first  injection  should  not  exceed 
three  drams,  as  some  patients  arc  exceedingly  susceptible  to  the  toxic 
action  of  iodoform.  1  n  one  of  two  of  my  ca.ses  laj)arotomy  and  drain- 
age were  resorted  to  several  limes,  and  each   attempt  was  followed 


676  PERITONITIS. 

by  a  speedy  relapse.  The  patients  were  then  tapped  at  intervals 
of  about  two  weeks,  and  each  time  from  three  to  four  drams  of 
a  10  per  cent,  emulsion  of  iodoform  glycerin  were  injected,  with 
the  result  that  after  two  and  five  injections  respectively,  the  hydrops 
disappeared  and  the  patients  recovered  and  remained  in  good 
health  two  and  three  years  after  the  last  tapping.  In  another 
case  of  exquisite  peritoneal  tuberculosis  and  tubercular  salpingitis 
the  disease  yielded  to  the  same  treatment  on  laparotomy  having 
been  performed.  Abdominal  section  and  intraperitoneal  iodo- 
formization  are  indicated  only  in  the  hydropic  form  of  peritoneal 
tuberculosis. 

TREATMENT  OF  SEPTIC  AND  SUPPURATIVE  PERITONITIS. 

I.  Ectoperitonitis. — The  surgical  treatment  of  an  ectoperito- 
nitic  suppurating  focus  is  curative  and  prophylactic.  The  prophy- 
laxis consists  in  the  prevention  of  rupture  of  the  abscess  contents 
into  the  free  peritoneal  cavity  by  an  extraperitoneal  incision  and 
drainage,  which  ordinarily  results  in  healing  of  the  abscess  cavity 
and  a  permanent  cure.  Paranephric  abscesses  should  be  treated 
by  lumbar  incision  and  drainage  ;  tubercular  spondylitic  abscesses 
without  fistula  formation,  by  tapping  and  iodoformization  ;  pelvic 
abscesses  in  the  female,  whenever  practicable,  by  vaginal  incision 
and  drainage.  If  the  abscess  is  not  within  reach  by  the  vaginal 
route,  an  incision  is  made  through  the  abdominal  wall  directly  over 
the  abscess,  and  in  the  absence  of  adhesions  the  parietal  peritoneum 
is  sutured  to  the  surface  of  the  abscess  wall  and  the  abscess  incised 
and  drained  at  once,  or  the  incision  is  tamponed  with  iodoform 
gauze  and  the  abscess  opened  and  drained  a  few  days  later  after  the 
peritoneal  cavity  has  been  more  thoroughly  excluded  by  the  forma- 
tion of  firm  adhesions. 

Suppurative  inflammation  of  the  loose  connective  tissue  in  the 
cavum  Retzii  often  leads  to  extensive  ectoperitonitis,  occasionally  to 
perforation  into  the  peritoneal  cavity,  septic  peritonitis,  and  death. 

Leusser  has  collected  forty-six  such  cases  and  has  made  some 
important  investigations  concerning  the  structure  and  arrangement 
of  the  tissues  in  the  prevesical  space  in  reference  to  the  directions 
in  which  the  pus  will  burrow  when  this  space  is  the  seat  of  a  phleg- 
monous inflammation.  He  found  that  the  loose  connective  tissue 
between  the  peritoneum  and  the  abdominal  muscles  is  divided  into 
two  layers  by  a  plane  of  fascia  that  is  inserted  into  the  upper  border 
of  the  symphysis.  An  abscess  in  this  region  may  therefore  be  sub- 
muscular  or  prevesical ;  the  former  occupies  the  space  between  the 
fascia  and  the  muscles  and  assumes  an  ovate  outline,  with  the  pointed 
extremity  of  the  swelling  directed  downward  ;  an  abscess  behind 
the  fascia,  a  true  prevesical  abscess,  resembles  in  outline  the  dis- 
tended bladder.  The  prevesical  abscess  can  be  reached  by  rectal 
and  vaginal  examination,  and  disturbs  the  function  of  the  bladder. 
The  indications  for  prompt  surgical    interference  are    particularly 


GENERAL    SEPTIC    PERITONITIS.  6/7 

urgent  when  the  abscess  is  deep, — subperitoneal, — as  it  is  in  such 
cases  that  the  peritoneum  is  extensively  involved  and  the  danger  of 
extensive  burrowing  of  the  pus  is  greatest,  and  perforation  into  the 
peritoneal  cavity  most  frequently  takes  place.  The  proper  treat- 
ment of  an  abscess  in  the  cavum  Retzii  is  an  early  and  free  incision 
made  in  the  same  manner  and  with  the  same  care  as  in  operations 
for  stone  in  the  bladder  by  the  suprapubic  route  and  extending  to 
the  anterior  wall  of  the  bladder. 

2.  General  Septic  Peritonitis. — The  greatest  confusion  still 
prevails  among  pathologists,  physicians,  and  surgeons  in  reference 
to  what  is  meant  by  general  septic  peritonitis,  more  particularly  as 
to  the  distinction  between  septic  and  suppurative  peritonitis.  By  a 
general  septic  peritonitis  is  understood  an  inflammation  of  the  entire 
peritoneal  sac  with  the  serous  covering  of  all  abdominal  organs, 
which,  as  a  rule,  proves  fatal  from  progressive  intoxication  before 
sufficient  time  has  elapsed  for  the  formation  of  pus  or  any  consid- 
erable transudate,  or  before  any  marked  macroscopic  tissue  changes 
ha\"e  occurred.  It  is  the  result  of  the  most  virulent  infection,  the 
patients  dying  not  so  much  from  the  effects  of  the  inflammation  as 
from  the  rapid  introduction  into  the  general  circulation  from  the 
peritoneal  cavity  of  preformed  septic  material.  In  suppurative  peri- 
tonitis the  primary  microbic  infection  is  less  in  quantity  or  virulence, 
and  a  sufficient  length  of  time  intervenes  between  the  beginning  of 
the  attack  and  the  operation  or  death  for  the  formation  of  pus  and 
other  inflammatory  products.  Every  acute  peritonitis  is  septic  in  so 
far  that  phlogistic  substances  reach  the  general  cire7ilatio7i  from  the 
inflaniniatory  lesion,  and  in  that  frequoitly  the  inflanwiation  terminates 
in  suppuration,  but  the  term  septic  should  be  limited  to  those  cases  of 
diffuse  septic  peritojiitis  in  which,  as  a  rule,  death  occurs  in  a  fezvdays 
and  before  any  gross  pathologic  conditions  have  had  time  to  develop. 
It  is  a  disease  that  is  almost  uniformly  fatal,  tvitli  or  tvithout  opera- 
tion, the  patients  dying  from  the  effects  of  progressive  sepsis.  The 
subjects  of  this  variety  of  peritonitis  die  so  soon  after  the  beginning 
of  the  disease  that  at  the  postmortem,  or,  if  the  abdomen  is  opened 
during  life,  at  the  operation,  no  gross  tissue  changes  are  discovered. 
Besides  a  slightly  increased  vascularity,  nothing  is  found  to  indicate 
the  existence  of  peritonitis.  The  septic  material,  formed  in  large 
quantities  and  of  inten.se  virulence,  is  rapidly  absorbed  by  the  .stomata 
of  the  under  surface  of  the  diaphragm,  discovered  and  described  by 
von  Recklinghausen. 

In  putrid  peritonitis  the  streptococcus  infection  is  complicated 
by  the  presence  of  putrescible  substances  which  serve  as  a  nutrient 
medium  for  .saprophytic  bacteria  which  modify  the  character  ot  the 
inflammatory  product.  It  occurs  most  frequently  in  connection 
with  grave  forms  of  puerperal  metritis.  It  is  usually  associated 
with  more  or  less  gangrene  or  ulceration  of  the  organ  or  parts 
primarily  affected,  as  the  uterus,  intestine,  or  abdominal  wall.  It  is 
diffu.se  septic  i)eritonitis  that  has  so  far  proved  so  obstinate  to  sue- 


678  PERITONITIS. 

cessful  surgical  treatment.  Surgery  has  done  much  toward  its  pre- 
vention, but  very  little  toward  saving  life  after  the  disease  has  once 
fully  developed.  Careful  analysis  of  the  cases  that  yielded  to  lapar- 
otomy would  undoubtedly  disclose  the  fact  that  most  of  them  were 
not  genuine  cases  of  general  septic  peritonitis,  but  cases  of  more  or 
less  localized  inflammation  of  the  peritoneum  with  or  without  sup- 
puration. In  this  opinion  I  am  supported  by  no  less  an  authority 
than  Frederick  Treves,  who,  from  a  surgical  standpoint,  divides 
peritonitis  into  localized  and  diffuse.  He  states  that  the  surgical 
treatment  of  the  former  has  yielded  encouraging  results,  but  in 
general  nontubercular  peritonitis  it  has  been  phenomenally  unsuc- 
cessful. After  speaking  of  circumscribed  peritonitis,  the  same 
author  says  :  "  Peritonitis  in  the  '  small  intestine  area '  is,  on  the 
other  hand,  rapidly  diffused,  and  is  as  rapidly  attended  by  septicemic 
symptoms.  In  the  treatment  of  localized  peritonitis  surgery  can 
claim  to  have  made  great  advances,  but  in  the  treatment  of  diffuse 
peritoneal  inflammation  with  marked  constitutional  symptoms  there 
is  little  progress  to  record.  The  abdomen  may  be  opened,  washed 
out,  and  drained,  and  the  distended  bowel  may  be  relieved  of  its 
putrescent  contents  by  incision,  but  the  results  at  the  best  are  not 
brilliant,  and  it  is  evident  that  the  treatment  of  this  terrible  compli- 
cation must  still  incline  toward  that  desirable  prevention  which  is 
better  than  cure." 

I  have  opened,  drained,  and  washed  out  the  peritoneal  cavity  in 
many  cases  of  diffuse  septic  peritonitis  and,  I  am  free  to  confess, 
without  a  single  successful  result.  All  my  cases  died  of  sepsis  a 
few  hours  to  a  day  or  two  after  the  operation,  in  spite  of  heroic 
stimulation  and,  in  some  cases,  of  frequently  repeated  irrigation 
with  steriHzed  water,  normal  solution  of  salt,  or  mild  antiseptic 
solutions,  such  as  boric  acid  and  acetate  of  aluminum.  On  the 
other  hand,  some  surgeons  report  a  fair  percentage  of  recoveries 
after  laparotomy  for  what  they  call  general  septic  peritonitis.  Krecke 
has  collected  1 19  cases  of  laparotomy  in  general  peritonitis,  the  origin 
of  which  was  determined  in  all  except  1 8,  of  which  9  died  and  9  re- 
covered. In  most  of  the  cases  the  disease  was  caused  by  perforation. 
Of  these,  36  followed  perforation  of  the  appendix,  12  were  cases  of 
•  typhoid  perforation,  of  which  5  recovered  ;  12  were  due  to  perforation 
from  gangrene  and  other  causes  implicating  the  intestines.  Of  the  gan- 
grenous variety,  not  one  recovered,  and  of  the  8  others,  only  3  were 
cured  by  the  operation.  Of  traumatic  cases,  3  of  punctured  and  i  of 
gunshot  wound,  all  recovered,  but  of  contusions  only  3  out  of  8  recov- 
ered. The  operation  saved  5  out  of  1 3  cases  of  puerperal  peritonitis. 
Lastly,  a  group  of  cases  of  peritonitis  from  various  other  causes 
yielded  3  deaths  and  6  recoveries.  The  total  result  is  1 19  cases  of 
general  peritonitis  treated  by  laparotomy,  with  5  i  recoveries  and  68 
deaths. 

A.  J.  McCosh  ("The  Treatment  of  General  Septic  Peritonitis," 
"Annals  of  Surgery,"  June,  1897)  operated  (1888  to  1895  inclu- 


MEDICAL    TREATMENT.  5^0 

sive)  in  43   cases  of  general  septic  peritonitis.      Of  these    xj  died 
and  6  recovered,  a  mortality  of  about  86  per  cent.      A  free  abdom 
inal  mcision   was  made  in  all,  and  with  a  {^^v  exceptions  irrigation 
was  employed.  ^ 

_  It  is  not  easy,  nor  alwa^-s  possible,  to  ascertain  the  extent  of 
mflammation  in  vivo  by  opening  the  peritoneal  cavity,  and  a  strong 
suspicion  remains  that  at  least  in  some  of  the  cases  that  recovered 
the  peritonitis  was  not  general,  or  that  the  operation  was  performed 
before  the  entire  serous  surfaces  were  involved.  Certain  principles 
in  the  medical  and  surgical  treatment  of  peritonitis  are  applicable  to 
all  forms  of  the  disease,  and  the  best  place  to  discuss  them  is  in 
coniiection  with  the  gravest  variety— acute  general  septic  peritonitis 

Medical  Treatment— A  more  general  discussion  of  the  medical 
treatment  of  peritonitis   is   out  of  place  here,  but  a  few  words  in 
reference  to  what  the  surgeon  should  do  and  what  he  should  not 
do  in  the  way  of  medical  treatment  when  he  assumes  charge  of  a 
case  of  peritonitis  is  pertinent  to  the   subject  under  consideration 
htomach  feeding  must  be  abstained  from  entirely  or  limited  to  the 
administration  of  liquid  food  and  stimulants.      If,  as  is  so  frequently 
the   case,   nausea   and  vomiting    are  prominent   symptoms    rectal 
enemata  are  of  the  greatest  value.      The  distressing  thirst  can  often 
be  effectually  relieved  by  high   rectal   enemata  of  warm  water  or 
normal  saline  solution  ;  if  these  are  not  tolerated,  by  hypodermic  in- 
iu.sion.     The  therapeutic  indications  for  cathartics  and  opium  in  the 
treatment    of  peritonitis    are    not    definitely   settled.      Some   favor 
cathartics,   others   condemn   them  and  rely   on  opium       Mr    Tait 
taught  us  years  ago  the  value  of  saline  cathartics  in  the  prevention 
of  peritonitis  and  in  its  treatment  during  the  incipient  stage      Most 
practitioners  have  adopted  his  views  and  administer  saline  cathartics 
as  soon  as  the  first  symptoms  make  their  appearance,  and  certainly 
the  results  have  been  much  better  since  this  practice  has  come  into 
more  general  use.      It  is  not  only  clinical  observation  that  supports 
laits  teachings  and  practice:  his  views   have  been  substantiated 
by  experimental  investigations.      The  experiments  of  Wegner  prove 
that  bacteria  injected   into  the  peritoneal  cavity  readily  enter  the 
blood-ves.sels  and  lymphatics  and  thus  reach  the  excretory  or-ans 
notably  the  mtestinal  canal,  through  which  they  are  rapidly  clfmin- 
ated  by  free  catharsis. 

Lavvson  Tait  has  found  the  most  efficient  treatment  for  septic 
conditions  following  abdominal  .section  to  be  thirty  or  forty  grains 
of  sulphate  of  magnesia,  repeated  every  hour  or  every  other  hour 
until  the  bowels  move  freely.  Hence,  when  microbes  accumulate 
m  such  quantities  that  nature  unaided  can  not  remove  them,  it  is 
rational  treatment  to  render  assistance  by  the  administration  of 
saline  cathartics  to  favor  the  process  of  elimination. 

I  have  .seen  manyca.scsof  threatened  peritonitis  after  abdominal 
.section  aborted  by  the  timely  administration  of  saline  cathartics. 
If  the  stomach  is  intolerant,  calomel  in  small  tloses,  repeated 
hourly,  and  saline  enemata  are  indicated. 


68o  PERITONITIS. 

One  of  the  greatest  dangers  in  peritonitis  is  rapid  distention  with 
paresis  of  the  intestines,  a  condition  that  is  provoked  by  opium 
and  that  can  be  most  effectually  averted  by  early  and  free  catharsis. 
The  use  of  cathartics  is  absolutely  contraindicated  in  all  cases  of 
peritonitis  caused  by  perforation.  In  such  cases  the  use  of  opium 
is  legitimate  and  useful,  as  it  diminishes  shock,  extravasation  of 
septic  material,  and  its  rapid  diffusion  over  the  peritoneal  surface. 
Peritonitis,  especially  the  septic  variety,  invariably  depresses  the 
heart's  action,  a  condition  that  should  be  met  by  active  stimulation. 
Shock,  general  debility,  and,  as  Fritsch  has  shown,  a  weak  heart 
increase  the  danger  from  sepsis.  Strychnin,  camphor,  and  alcoholic 
stimulants  should  be  employed  early  and  at  short  intervals  in  all 
cases  of  grave  peritonitis.  If  these  remedies  are  not  retained  by 
the  stomach,  they  must  be  administered  subcutaneously  or  by  the 
rectum.  The  application  of  ice  or  the  cold  coil  over  the  abdomen 
frequently  succeeds  in  diminishing  the  tympanites,  and  should  be 
employed  to  prevent  overdistention  and  paresis  of  the  intestines 
when  this  condition  appears  and  the  peripheral  circulation  warrants 
their  use.  If  the  heart's  action  is  weak  and  the  capillary  circulation 
sluggish,  hot  applications  are  more  agreeable  to  the  patient  and  a 
better  stimulant  for  the  feeble  peripheral  circulation. 

Operative  Treatment. — There  can  be  no  difference  of  opinion 
in  reference  to  the  advisability  of  early  operative  treatment  in  the 
management  of  diffuse  septic  peritonitis.  Without  operation  death 
is  almost  certain.  An  early  operation  may  succeed  in  arresting  fur- 
ther extension  of  infection  in  cases  in  which  the  disease  would 
become  general,  and  in  diffuse  cases  may  occasionally  be  the  means 
of  saving  a  life  that,  without  it,  would  be  surely  lost.  An  early 
diagnosis  and  prompt  operative  interference  are  the  conditions  sine 
qua  non  for  success.  The  patient  should  be  properly  prepared  for 
the  operation,  not  only  with  a  view  to  securing  absolute  asepsis  for 
the  field  of  operation  and  everything  that  is  to  be  brought  in  con- 
tact with  the  wound,  but  the  necessary  precautions  should  also  be 
carried  into  effect  to  sustain  the  heart's  action  and  stimulate  the 
capillary  circulation  during  and  immediately  after  the  operation. 
This  can  be  accomplished  by  administering  JL.  of  a  grain  of  strych- 
nin, if  the  patient  is  an  adult,  hypodermically,  and  two  ounces  of 
whisky  or  brandy  by  the  stomach  or  rectum  half  an  hour  before 
the  anesthetic  is  administered.  I  am  partial  to  the  use  of  sulphuric 
ether  as  an  anesthetic  in  performing  laparotomy  for  this  indication, 
as  it  has  a  less  injurious  effect  on  the  already  enfeebled  circulation 
than  chloroform.  The  body  must  be  carefully  protected  against 
loss  of  heat  during  the  administration  of  the  anesthetic  and  the 
performance  of  the  operation,  by  warm  flannel  blankets  and  bottles 
or  rubber  bags  containing  hot  water. 

The  normal  salt  solution  and  antiseptic  solutions  that  are  to  be 
used  for  irrigation  must  be  kept  at  a  temperature  of  from  iio°  to 
1 20°  F.      Different  kinds  of  drains  and  drainage  material  should  be 


HISTORY    OF    OPERATION    FOR    TREATMENT.  68 1 

on  hand  to  be  used  as  indications  may  arise.  The  handling  of  the 
patient  must  be  done  with  the  utmost  care  and  gentleness. 

History  of  Operation  for  Peritonitis. — For  centuries  abscesses 
that  had  their  origin  in  the  peritoneal  cavity  have  been  opened  after 
they  presented  themselves  as  such  upon  any  of  the  accessible  sur- 
faces. Laparotomy  as  a  therapeutic  resource  in  the  treatment  of 
peritonitis  is  of  recent  date.  J.  Ewing  Mears  as  early  as  1875 
operated  by  abdominal  section  in  a  case  of  circumscribed  suppu- 
rative peritonitis  following  childbirth.  He  advocated  at  that  time 
surgical  intervention  in  all  cases  of  suppurative  peritonitis.  Treves 
reported  a  case  of  acute  peritonitis  treated  by  abdominal  section  in 
1885,  which  terminated  in  recovery,  and  he  recommended  the  oper- 
ation in  similar  cases.  During  the  same  year  Pean  advocated  in  the 
treatment  of  septic  peritonitis  incision  toilet  and  drainage  of  the  ab- 
dominal cavity.  He  favored  a  large  median  incision,  removal  of 
inflammatory  product  with  sponges  and  napkins,  closure  of  wound 
by  suturing,  except  a  place  large  enough  for  drainage.  About  the 
same  time  Oberst  urged  energetic  surgical  treatment  in  cases  of 
acute  peritonitis.  In  the  acutest  form,  howe\'er,  he  admitted  that 
abdominal  section  and  drainage  were  powerless  in  averting  death 
from  sepsis.  In  1886  Lawson  Tait  reported  two  cases  of  acute 
peritonitis  treated  by  abdominal  section,  of  which  one  recovered. 
He  advised  laparotomy  in  all  cases  of  peritonitis  if  an  effusion  can 
be  demonstrated  and  the  existence  of  fever  indicates  the  pyogenic 
nature  of  the  inflammatory  product. 

In  1889  successful  laparotomies  for  septic  peritonitis  were  re- 
ported by  Demons,  Bouilly,  Dernuce,  Brun,  Labbe,  and  Routier. 
It  is  evident  that  in  most  of  these  cases  the  operation  was  performed 
for  circumscribed  suppurative  and  not  for  diffuse  septic  peritonitis. 

The  treatment  of  peritonitis  by  laparotomy  received  a  new  im- 
petus when,  about  twelve  years  ago,  it  was  found  that  the  disease 
is  so  often  produced  by  primary  suppurative  and  perforative  lesions 
of  the  appendix  vermiformis.  About  the  same  time  gynecologists 
began  to  treat  suppurative  lesions  of  the  pelvis,  so  frequently  the 
precursors  of  a  similar  affection  of  the  peritoneum,  upon  sound  sur- 
gical principles.  The  old  dictum,  iibi  pus  ibi  evac?io,  is  now  fully 
appreciated  by  surgeons  and  gynecologists,  and  is  daily  put  in  prac- 
tice in  the  treatment  of  sup[)urative  ectoperitonitis  and  septic  and 
suppurative  peritonitis.  Future  clinical  ex[)erience  and  experi- 
mental research  will  make  this  department  of  surgery  one  of  the 
greatest  blessings  to  humanity. 

Incision. — In  the  operative  treatment  of  general  septic  peritonitis 
authorities  are  as  yet  not  agreed  as  to  the  size,  location,  and  number 
of  incisions  that  should  be  employed  in  opening  the  abdominal 
cavity.  In  circumscribed  peritonitis,  the  rule,  to  inci.se  and  drain 
by  the  shortest  and  most  direct  route,  is  usually  followed.  In  per- 
foration of  any  other  organ  except  the  ap|)endix  vermiformis  result- 
ing in  diffu.se  peritonitis,  tiie  first  incision  should  always  be  made  at 


682  PERITONITIS. 

or  near  the  median  line.  The  incision  is  made  above  the  umbilicus 
if  the  gall-bladder,  stomach,  or  duodenum  is  the  seat  of  perforation  ; 
below  the  umbilicus,  in  perforation  of  any  other  portion  of  the  small 
intestines. 

Mikulicz  makes  a  sharp  distinction  in  the  treatment  of  diffuse 
septic  and  progressive  fibropurulent  peritonitis.  In  the  former 
variety  the  abdominal  incision  should  be  large,  the  perforation 
closed,  and  the  abdominal  cavity  disinfected  and  drained.  In  the 
latter  the  adhesions  should  be  carefully  preserved  and  the  different 
pus  accumulations  opened  and  evacuated  separately.  Some  sur- 
geons prefer  to  open  the  abdomen  some  distance  from  the  linea 
alba. 

Ramsay  gives  cogent  reasons  why,  in  opening  the  abdominal 
cavity,  the  incision  should  not  be  made  in  the  median  line,  but 
through  the  center  of  either  rectus  muscle,  where  the  abdominal 
wall  is  thickest  and  strongest,  and  where  the  different  layers  can 
be  sutured  separately  with  the  greatest  ease,  and  where,  for  these 
reasons,  ventral  hernia  is  least  likely  to  follow  as  one  of  the  remote 
consequences  of  the  operation.  Prolonged  drainage  is  always  an 
important  etiologic  element  in  the  occurrence  of  postoperative  ven- 
tral hernia,  and  this  complication  is  certainly  less  likely  to  follow 
if  the  incision  is  made  through  the  muscular  portion  of  the  ab- 
dominal wall  than  through  the  thin  fibrous  linea  alba. 

In  the  treatment  of  diffuse  septic  peritonitis  the  incision  should 
be  at  least  large  enough  to  insert  the  hand  for  the  purpose  of  mak- 
ing a  careful  intra-abdominal  exploration  with  a  view  to  ascertain- 
ing the  extent  of  the  disease  and  to  locate  and,  if  possible,  treat 
the  primary  lesion.  Gill  Wylie  recommends,  in  the  surgical  treat- 
ment of  diffuse  peritonitis,  an  incision  of  this  size  to  enable  surgeons 
to  break  up  all  adhesions  among  the  intestines,  and  to  wash  freely 
the  entire  cavity  of  the  peritoneum  and  insert  two  or  more  drainage- 
tubes.  The  question  relating  to  the  propriety  of  breaking  up  ad- 
hesions will  be  discussed  elsewhere,  as  in  the  form  of  peritonitis  that 
is  now  under  consideration  adhesions,  as  a  rule,  are  absent,  or,  if 
present,  few  and  slight.  As  has  been  stated  before,  the  incision 
should  be  large  enough  to  enable  the  surgeon  to  find  and  treat  the 
primary  affection  that  caused  the  peritonitis. 

Mr.  Bowlby  is  of  the  belief  that  an  incision  below  the  umbilicus 
does  not  necessarily  empty  the  peritoneal  cavity.  In  the  one  case, 
after  incising  and  flushing  out  through  a  subumbilical  incision,  he 
found  a  large  quantity  of  gas  as  well  as  fluid  remaining  in  the 
peritoneal  cavity  above.  In  cases  of  peritonitis  resulting  from  per- 
foration of  a  gastric  or  duodenal  ulcer  he  advises  two  incisions  (one 
above  and  one  below  the  umbilicus),  to  insure  complete  flushing. 
In  diffuse  peritonitis  incisions  should  be  made  at  a  number  of  points 
with  a  view  of  facilitating  irrigation  and  of  insuring  free  drainage. 
The  best  points  will  be  above  the  pubis  and  above  the  umbilicus,  and 
posteriorly  through  the  lumbar  region  on  each  side  ;  in  the  female 


EVENTRATION. 


683 

through  drainage  into  the  vagina,  by  incising  the  Douglas  culdesac 
will  answer  an  excellent  purpose.  A  long  incision,  permitting  the 
intestines  to  escape  from  the  abdominal  cavity  and  covering  them 
with  a  piece  of  gutta-percha  rubber  tissue,  which  is  sutured'^to  the 
margins  of  the  wound,  a  method  of  treatment  suggested  by  Hadra 
of  Texas,  is  based  entirely  upon  theoretic  grounds  and  is  too  haz- 
ardous to  merit  a  trial. 

McBurney  has  devised  an  incision  for  operations  on  the  appen- 
dix that  reduces  to  a  minimum  the  risks  of  a  subsequent  formation 
of  a  ventral   hernia.      "  The   skin   incision    is   oblique,    about  four 
inches   in   length,  crossing  at  a  right  angle  a  line  drawn   from  the 
spme  of  the  ilium  to  the  umbilicus,  and   about  an  inch    from  the 
spine.     This  incision  is  a  little  to  the  outer  side  of  the  normal  situ- 
ation of  the  appendix.      The  fibers  of  the  external  oblique  and  its 
aponeurosis   are   not  cut,  but  are  separated  with   great  care  in  the 
direction  in  which  they  run.      When  the  edges  of  the  wound  of  the 
external  oblique  are  separated  with  retractors,  a  considerable  ex- 
panse of  internal  oblique  muscle  is  seen,  the  fibers  of  which  cross 
somewhat  obliquely  the  opening  formed  by  the  retractors.      With  a 
blunt  instrument  the  fibers  of  the  internal  oblique  and  transversalis 
muscles  can  be  separated  without  cutting  more  than  an  occasional 
fiber  in  a  line   parallel  with   their   course— that  is,  nearly  at   right 
angles  to  the  incision  in  the  aponeurosis.      Blunt  retractors  are  now 
introduced,  and  these  expose  the  transversalis  fascia,  which  is  then 
divided  in  the  same  line  ;  last  of  all,  the  peritoneum  is  divided." 
This  incision  is  an  ideal  one  in  the  removal  of  a  diseased  appendix 
not    complicated    by  suppurative    periappendicitis.      In    the    latter 
event  the  incision  must  be  large  enough  to  enable  the  surgeon  to 
see  what  he  is  doing  in  order  to  avoid  injuring  important  neighbor- 
ing organs.      It  will  be  seen,  from  what  has  been  said,  that  no  fixed 
rules  can  be  laid  down  and  followed  in  regard  to  the  size,  location, 
and  number   of  incisions   to   be  made  in   opening  the  abdominal 
cavity  for  peritonitis.      The   surgeon  must  be  guided  by  his  own 
judgment  and  adopt  plans  and  methods  applicable  to  each  individ- 
ual   ca.se    rather    than   follow,  as  is   only   too   frequently  done,   a 
routine  practice. 

Eveutratioji. — A  number  of  surgeons  favor  eventration  after  in- 
cising the  peritoneal  cavity  freely,  for  the  purpose  of  effecting  more 
thorough  disinfection.  In  septic  peritonitis  the  serous  coat  of  the 
intestines  is  always  damaged,  and  frequently  the  muscular  coat  is 
in  a  condition  of  paresi.s.  The  intestines  are  also  usually  very  much 
di.stended.  These  conditions  render  them  very  liable  to  be  injured 
and  even  ruptured  when  extensive  eventration  is  made,  to  say 
nothing  of  the  shock  that  always  attends  such  a  procedure,  not- 
withstanding that  the  greatest  care  is  exercised  in  protecting  them 
with  warm  moist  compresses. 

Olshau.scn  has  called  attention  to  the  danger  of  eventration 
and    prolonged  exposure   of   the   healthy   intestines   in  abdominal 


684  PERITONITIS. 

operations.  He  reported  several  cases  in  which  adynamic  ileus 
and  death  followed  laparotomy  that  could  be  traced  to  no  other 
cause.  Gusserow  recognizes  the  danger  from  these  sources,  and 
guards  against  them  by  retaining  the  intestines  in  the  abdominal 
cavity  with  large  flat  sponges.  If  such  baneful  results  follow  even- 
tration and  exposure  of  healthy  intestines,  it  is  not  difficult  to  con- 
ceive that  the  danger  from  the  same  source  in  laparotomy  for 
peritonitis  would  be  increased  tenfold.  The  feeble  circulation  and 
the  increased  sensitiveness  of  the  inflamed  viscera  in  such  cases 
would  necessarily  greatly  increase  the  shock  and  aggravate  the 
already  existing  intestinal  paresis.  If  eventration  is  practised  for 
the  purpose  of  relieving  the  overdistended  intestines,  a  limited  part 
of  the  intestine  should  be  brought  forward  in  the  wound.  When 
prolapsed,  the  loop  is  incised  or  punctured,  emptied  of  its  contents, 
the  visceral  wound  sutured,  and  the  loop  douched  with  hot  saline 
solution,  dried  and  returned.  Extensive  eventration  is  dangerous 
and  must  be  scrupulously  avoided. 

Irrigation. — The  subject  of  irrigation  in  the  surgical  treatment 
of  peritonitis  has  been  frequently  discussed,  but  so  far  no  positive 
final  conclusions  have  been  reached.  Some  surgeons  invariably 
irrigate  ;  others  believe  that  irrigation  does  more  harm  than  good, 
and  are  content  to  remove  the  inflammatory  product  by  means  of 
sponges.  It  is  generally  conceded  that  in  diffuse  peritonitis  it  is 
impossible,  by  any  known  methods  of  irrigation,  to  remove  all  the 
infectious  material  from  the  peritoneal  cavity.  In  diffuse  septic 
peritonitis  the  patients  die  from  the  effects  of  sepsis  caused  by  the 
absorption  of  septic  material  from  the  peritoneal  cavity,  and  the  sur- 
geon resorts  to  irrigation  almost  instinctively  to  diminish  the  danger 
from  this  source.  The  use  of  strong  antiseptic  solutions  has  been 
abolished,  owing  to  the  danger  from  intoxication  resulting  from  the 
rapid  absorption  of  the  antiseptic  employed  and  the  damage  that 
results  from  the  irritating  germicides  when  applied  to  the  endothe- 
lial cells  lining  the  peritoneal  sac.  Sterilized  normal  physiologic 
solution  of  salt,  solutions  of  boric  acid  and  acetate  of  aluminum, 
and  Thiersch's  solutions  are  now  most  frequently  used  in  washing 
out  the  peritoneal  cavity.  Whatever  medium  is  employed  should 
be  used  at  a  temperature  of  from  iio°  to  115°  F.,  and  the  stream 
should  be  sufficiently  large  and  strong  to  wash  out  the  most  remote 
corners  of  the  peritoneal  cavity  in  the  direction  of  the  drainage 
opening  or  openings. 

Reichel's  experimental  attempts  to  treat  successfully  septic  peri- 
tonitis artificially  produced  in  animals  were  almost  entirely  a  failure. 
Irrigation  of  the  peritoneal  cavity  with  sublimate,  chloroborate  of 
soda,  salicylic  acid,  etc.,  was  useless— the  animals  quickly  perished. 
Laparotomy  performed  for  the  purpose  of  cleansing  the  peritoneal 
cavity  after  the  introduction  of  fecal  matter,  and  prior  to  the  devel- 
opment of  peritonitis,  according  to  Reichel,  is  not  only  useless,  but, 
even  in  healthy  animals,  proved  to  be  an  injurious  measure.     Some- 


IRRIGATION.  685 

what  better  results  were  obtained  by  gently  sponging  the  peritoneal 
surfaces,  after  opening  the  abdominal  cavity,  with  gauze  sponges, 
and  employing  the  Mikulicz  gauze  drain.  In  nine  experimental 
cases  in  dogs  two  recoveries  were  obtained  by  this  method.  Reichel 
believes  successful  operative  treatment  is  applicable  only  in  cases 
of  circumscribed  empyema-like  pus  accumulations. 

Delbet  speaks  more  favorably  of  the  results  of  irrigation  of  the 
peritoneal  cavity  in  cases  of  general  peritonitis  from  an  experimental 
standpoint.  He  ascertained,  by  experiments  on  animals,  that  if  the 
peritoneal  cavity  is  irrigated  for  ten  minutes  with  a  physiologic  solu- 
tion of  salt,  toxic  substances  can  be  introduced  without  causing 
peritonitis  or  death  from  intoxication  if  the  infection  is  followed  by 
another  irrigation  with  the  same  solution.  He  advocates  the  use 
of  salt  solution  in  operations  on  the  abdominal  cavity  when  contami- 
nation takes  place  during  the  operation  and  in  the  operative  treat- 
ment of  septic  peritonitis. 

Mr.  Barker  has  found  by  experience  that  a  very  convenient 
method  of  flushing  the  abdominal  cavity  is  to  use  a  can  with  three 
taps,  to  which  tubes  of  large  caliber  are  attached,  and  thus  the  peri- 
toneal cavity  can  be  flushed  from  several  points  at  once,  the  fluid 
flowing  out  throucrh  the  original  incisions.  He  uses  fluids  for 
flushing  at  105°  F. 

Wiggin  believes  that  the  use  of  peroxid  of  hydrogen,  followed 
b}-  plenty  of  normal  salt  solution,  is  most  beneficial  in  disinfecting 
the  peritoneal  cavity  and  in  preventing  adhesions.  He  claims  that 
many  otherwise  successful  laparotomies  are  followed  by  such  exten- 
sive and  painful  adhesions  that  the  patients  are  left  in  a  worse  state 
than  before  operation,  and  the  observance  of  this  simple  rule  would 
avoid  so  disagreeable  a  result.  Continuous  irrigation,  so  useful  in 
the  treatment  of  septic  wounds  in  other  localities,  has  been  sug- 
gested in  the  treatment  of  general  peritonitis.  In  1894  Oscar  Allis 
recommended  in  the  treatment  of  general  .septic  peritonitis,  abdominal 
section,  liberation  of  pus  from  all  pockets  by  tearing  adhesions, 
continuous  irrigation,  the  local  application  of  cerate  to  the  walls  of 
the  suppurating  cavities,  the  prone  position,  and  to  keep  the  wound 
open  by  tucking  a  rubber  dam  covered  with  cerate  between  the 
abdominal  wall  and  the  intestines  on  each  side,  with  one  border 
emerging  from  the  incision.  He  believes  that  under  a  continuous 
system  of  flushing  or  irrigation  the  wash  products  would  be  made 
to  float  constantly  to  the  surface,  and  be  more  effectually  carried  off 
than  by  dependent  dorsal  drainage.  The  peritoneal  cavity  can  not 
be  flushed  continuously  for  any  length  of  time,  as  adhesions  will 
soon  form  around  the  drainage-tubes  and  between  the  intestinal 
coils. 

In  acute  .se[jtic  peritonitis,  however,  continuous  irrigation  de- 
serves a  fair  trial,  and  its  therapeutic  value  has  recently  i)een  em- 
phasized by  the  brilliant  results  of  Laplace.  The  fluid  to  be  used 
should  be  introduced  into  the  lowest  portion  of  the  abdominal  cavity 


686  PERITONITIS. 

through  a  nonfenestrated  rubber  tube,  and  seek  escape  through  the 
rubber  tubes  above  the  umbilicus  and  in  the  lumbar  regions. 

The  propriety  of  tearing  up  adhesions  for  the  purpose  of  making 
the  irrigation  more  thorough  is  very  questionable,  and,  as  a  rule, 
should  be  avoided.  The  so-called  toilet  by  using  sponges  must  be 
done  with  the  utmost  gentleness,  if  resorted  to  at  all,  as  all  mechan- 
ical insults  inflicted  on  the  endothelial  surface  are  sure  to  aggravate 
the  existing  conditions.  If  it  is  intended  to  remove  the  fluid  from 
the  peritoneal  cavity,  it  is  better  to  do  so  by  placing  the  patient  on 
the  side,  so  as  to  pour  it  out  instead  of  removing  it  by  mopping. 
If  no  irrigation  is  employed  and  the  peritoneal  cavity  contains  a 
transudate  of  serum  or  pus,  the  fluid  should  be  disposed  of  in  the 
same  way,  after  which  the  more  thorough  cleansing  can  be  effected 
by  the  gentle  use  of  a  soft  sea-sponge. 

Incision  of  Overdistended  Intestine. — One  of  the  most  unfavor- 
able conditions  in  peritonitis  is  overdistention  of  the  intestines  with 
gas  and  septic  fluid  material.  A  paretic  inflamed  intestine  is  per- 
meable to  pathogenic  microbes,  thus  adding  another  fruitful  source 
of  infection  to  the  existing  septic  inflammation.  Death  from  periton- 
itis is  the  result  more  of  rapid  intoxication  than  of  the  inflammation 
itself.  The  inflammation  of  the  visceral  peritoneum  of  the  intestines 
leads  to  paralysis  of  the  muscular  coat,  rapid  distention,  and  the 
escape  of  preformed  toxins  and  bacteria.  Boennecken's  experiments 
have  shown  that  the  latter  occurs  in  a  remarkably  short  time.  It  is 
natural  that  surgeons  should  have  made  attempts  to  remove  disten- 
tion and  unload  the  intestines  of  septic  material  by  tapping  or  by 
making  one  or  more  visceral  incisions. 

Mixter  advises  this  procedure  in  grave  cases  of  general  peri- 
tonitis. He  recommends  incision  of  the  coils  of  the  paretic  intes- 
tines at  as  many  points  as  may  be  necessary  thoroughly  to  evacuate 
them.  The  intestine  should  be  drawn  out  of  the  wound,  held  over 
a  basin,  incised  in  from  one  to  four  places,  and  thoroughly  emptied, 
after  which  the  coils  should  be  quickly  washed  off  with  a  hot  saline 
solution,  the  visceral  wounds  sutured,  the  intestine  returned,  and  the 
abdominal  incision  closed.  Mixter  has  resorted  to  this  procedure 
in  nearly  twenty  cases,  some  of  which  recovered,  and  in  those  that 
died  the  visceral  wounds  were  found  to  be  tight.  In  some  cases, 
particularly  in  those  that  have  had  an  abdominal  incision  on  the 
right  side,  I  secure  permanent  drainage  by  introducing  a  tube  into 
the  most  prominent  part  of  the  cecum  and  retain  it  as  long  as  neces- 
sary. Through  this  tube  the  medicines  and  nourishment  may  be 
introduced  if  the  stomach  is  not  retentive.  In  a  paper  read  before 
the  Royal  Medical  and  Surgical  Society,  Mr.  C.  B.  Lockwood  ad- 
vocated puncture  and  incision  of  the  paretic  intestine  in  cases  of  dif- 
fuse septic  peritonitis  treated  by  abdominal  section.  Incision  of  the 
intestine  for  the  purpose  of  relieving  distention  and  evacuating  septic 
contents  was  favored  by  Hulke,  Knowsley  Thornton,  and  Barker. 
In  the  few  cases  in  which  McCosh  incised  the  intestine  he  noticed 


DRAINAGE. 


687 

that  it  did  not  relieve  the  distention  for  a  distance  of  more  than  ten 
or  twelve  inclies. 

I  have  made  visceral  incisions  in  a  number  of  cases  in  which 
tlie  mtestme  had  become  paretic,  and  although  but  one  of  the  cases 
recovered,,  I  am  fairly  convinced  that  it  is  almost  essential  to  suc- 
cess m  such   desperate   cases.      I  am  in  the   habit  of  placincr  the 
patient  on  the  side  and  bringing  the  most  distended  part  ol"  the 
mtestme  well  forward  into  the  wound,  and  making  a  transverse  in- 
cision about  an  inch  in  length  opposite  the  mesenteric  attachment 
As   the    intestinal   wall    does  not    contract,   evacuation   should  be 
secured  by  pouring  out  the  contents  from  above  and  below  the  in- 
cision b>'  grasping  the  intestine  some  distance  from  the  incision  and 
bringing  it  above  the  level  of  the  visceral  incision.      By  this  method 
several  feet  of  intestine   can  be    evacuated   through   one   incision 
After   thorough  cleansing  of  the   exposed  intestinal   surface  with 
warm  salt  solution,  the  wound  is  sutured  in    the  usual  manner  and 
the  intestine  returned.      If  more  than  one  incision  is  made   it  is  not 
difficult  to  conceive  that  irrigation  of  the  intestinal  tract'  between 
them  with  a  warm  normal  solution  of  salt  would  secure  a  more 
thorough  cleansing  of  that  part  of  the  intestinal  tract  and  would  be 
a  potent  means  of  restoring  intestinal  peristalsis. 

Dramao-e.— Drainage  of  the  abdominal  cavity  after  operations 
for  peritonitis  is  an  admission  of  the  present  imperfect  state  of  sur- 
ger>'.      It  is  an  acknowledgment  on  the  part  of  the  surgeon  that  he 
has  only  in  part  fulfilled  the  indications  for  which  the  operation  was 
performed  ;  it  is  a  confession  that  he  was  not  able  to  accomplish 
vvhat  was  so  much  needed  and  what  he  so  earnestly  desired— com- 
plete asepsis  of  the  entire  peritoneal  cavity.      With  the  means  at  our 
disposal  at  the  present  time  drainage  in  the  surgical  treatment  of 
peritonitis  is  an  unavoidable  evil.     The  question  that  confronts   us 
now  is  not  when,  but  how,  to  drain  in  such  ca.ses.      In  1870  durin^r 
the  Franco-Prussian  war,  Marion  Sims  made  a  special  study  of  thS 
cause  of  death  in  cases  of  gunshot  wounds  of  the  abdomen.     The 
result  of  his  observations  led  him  to  the  conclusion  that,  independently 
of  shock  and  hemorrhage,  death   resulted  from  sepsis.      He  found 
that  with  few  exceptions,  if  the  bullet  entered  above  the  pelvis,  the 
case  was  fatal,  while  similar  wounds  of  the  pcKic  portion  of  the 
abdominal  cavity  ended  in   recovery.      He  ascribed  this  difference 
in  the  mortality  to  the  circum.stance  that  high  wounds  resulted  in 
extrava.sation  of  intestinal  contents  which  accumulated  in  the  pelvic 
cavity,  while  in  pelvic  wounds  the  track  made  bv  tli^  bullet  served 
as  a  drainage  canal.      In   [872  he  recommended  that  in  all  penetrat- 
ing wounds  of  the  abdomen  and  in  operations  on  any  of  its  contents 
drainage  should  be  established.      In   ovariotomy  he  recommended 
tubular  drainage  through  the  wound  and  vagina,  using  for  this  pur- 
po.se  a  large  rui>ber  drain.      Very  few  surgeons  at  the  present  day 
wouhi  feel  justified  in  opening  the  abdominal  cavity  for  peritonitis 
and  di.spensing  with  drainage.      Voices  have,  however,  been   raised 


68S  PERITONITIS. 

against  too  frequent  resort  to  drainage,  among  them  that  of 
Olshausen,  who  says  :  "  Drainage  of  the  peritoneal  cavity  is  an  illu- 
sion. Drainage  to  be  of  service  must  be  limited  to  the  evacuation 
of  preformed  pathologic  spaces." 

Removal  of  fluid  pathologic  products  by  gentle  sponging  accom- 
plishes the  same  object.  The  absorptive  power  of  the  peritoneum 
should  be  preserved  as  much  as  possible  by  handling  with  the 
utmost  gentleness.  Prolonged  and  rough  manipulation  of  the  in- 
testines is  productive  of  great  shock.  Drainage  is  always  attended 
by  the  danger  of  putrefaction  bacilli  entering  into  the  peritoneal 
cavity.  In  perforating  wounds  he  recommends  a  careful  cleansing, 
complete  hemostasis,  avoiding  drainage  in  all  recent  cases. 

Barker  has  largely  dispensed  with  drainage  of  the  abdominal 
cavity  for  suppurative  lesions.  He  relies  mainly  on  thorough 
flushing,  and  sutures  the  abdominal  incision.  He  resorts  to  drain- 
age only  in  the  treatment  of  putrid  abscesses  caused  by  appendici- 
tis. If  a  drain  is  used  in  exceptional  cases  of  peritonitis,  he  advises 
its  removal  at  the  expiration  of  twenty-four  hours. 

The  difficulties  encountered  in  draining  the  peritoneal  cavity 
become  very  apparent  in  following  the  work  of  Bardenheuer.  He 
describes  four  methods  in  operation  on  the  abdominal  and  pelvic 
cavities  of  women.  The  first  method  is  by  a  T-shaped  tubular 
drain,  of  which  only  the  transverse  piece  is  fenestrated  and  the  ver- 
tical portion  brought  out  behind  the  uterus  into  the  vagina.  The 
second  method  consisted  in  using  two  transverse  drains  instead  of 
one,  fastened  together,  of  which  the  four  ends  were  sutured  to  the 
pelvic  floor  with  catgut.  The  third  method  had  in  view  the  pre- 
vention of  prolapse  of  the  intestines  by  using  a  fenestrated  rubber 
plate  above  the  drains,  which  was  sutured  to  the  pelvic  peritoneum. 
This  method  proved  useful  for  the  first  four  to  six  days  ;  after  this 
time  putrefaction  of  the  contents  of  the  cavity  invariably  set  in. 
The  subsequent  removal  of  the  plate  through  the  vagina  also 
proved  troublesome  and  often  deleterious.  The  last  method  con- 
sisted in  the  use  of  a  catgut  net  with  meshes  six  centimeters  wide, 
sewed  to  the  pelvic  floor  above  the  two  rubber  drains.  The  pelvic 
peritoneum  was  always  united  to  the  vaginal  mucous  membrane 
by  suture.  This  method  proved  eminently  satisfactory,  but  it  is 
doubtful  if  it  still  remains  in  use  in  his  practice  ;  certainly  it  has 
never  been  generally  adopted. 

Methods  of  Drainage. — At  present  there  are  three  methods  of 
drainage  in  general  use:  (i)  Tubular  drainage;  (2)  capillary 
drainage  ;  (3)  a  combination  of  tubular  and  capillary  drainage.  All 
these  methods  have  their  advocates  and  are  applicable  under  cer- 
tain circumstances.  No  one  method  of  drainage  will  answer  in  all 
cases. 

Tubular  drainage  :  Tubular  drainage  is  specially  indicated  in 
cases  in  which  the  abdominal  cavity  contains  pus.  The  tubes  em- 
ployed are  made  of  either  glass  or  soft  rubber.      Keith's  glass  drains 


DRAINAGE. 


689 

answer  an  excellent  purpose  in  draining  the  lowest  portion  of  the 
abdominal  cavity.  The}-  should  be  slightly  curved  at  the  abdom- 
mal  end,  so  as  to  reach  the  floor  of  the  pelvic  cavity  without  making 
harmful  pressure  against  the  bladder.  Frequent  aspiration  of  the 
contents  of  the  drain  is  necessary  for  the  purpose  of  removing  the 
fluid  niflammatory  product  as  soon  as  it  is  formed.  The  rubber 
drain  answers  the  same  purpose,  but  is  properly  accused  of  caus- 
mg  more  mechanical  irritation  than  the  smooth'  glass  tube.  Pro- 
longed tubular  drainage  has  not  infrequently  caused  intestinal  fistula 
by  pressure.  It  is  for  this  reason  that  I  almost  invariablv  surround 
the  rubber  or  glass  tube  with  a  few  lavers  of  iodoform  o-auze 
.  securely  fastened  to  the  tube.  In  draining  the  pelvic  portion  of  the 
abdominal  cavity  I  frequently  use  two  drains  the  size  of  the  little 
finger,  one  on  each  side,  brought  out  through  the  same  openincr  in 
the  lower  angle  of  the  wound.  In  draining  in  the  lumbar  recrfons 
and  through  the  vagina  rubber  drains  should  be  employed.      ^ 

Capillary  drainage  :  Capillar}^  drains  are  frequently  employed 
as  substitutes  for  the  tubular  drains,  and  in  addition  must  often'  be 
relied  upon  as  an  important  hemostatic  resource  in  arresting  paren- 
chymatous oozing.  Iodoform  or  sterilized  gauze  is  usually  em- 
ploxed  as  a  capillar)-  drain  in  draining  the  abdominal  cavity  for 
peritonitis.  Bardenheuer  first  resorted  to  strips  of  iodoform  gauze 
in  draining  the  peritoneal  cavity.  The  greatest  objections  tS  this 
method  of  drainage  are  the  danger  from  iodoform  poisoning  if  a 
considerable  quantity  of  gauze  is  used,  the  difficulty  of  remSvincr 
the  gauze,  and  the  likeHhood  of  a  ventral  hernia  as  a  legacy.  *" 

The  name  of  Mikulicz  is  connected  with  a  special  method  of 
gauze  drainage  of  his  own  device,  familiarl>-  known  as  the  Mikulicz 
iodoform  gauze  tampon  or  drain,  which  has  proved  of  the  greatest 
value  in   abdominal    operations   and  in   the   surgical  treatment   of 
peritonitis.      The  typical  Mikulicz  tampon  is  made  by  taking  a  piece 
of  iodoform  gauze  the  size  of  a  large  handkerchief,  to  the  center  of 
which  a  strong  piece  of  aseptic  silk  thread  is  stitched.      When  used, 
It  IS  arranged  as  a  pouch  and  is  carried  by  means  of  a  curved  for- 
ceps to  the  bottom  of  the  pelvis,  and  filled  with  strips  of  iodoform 
gauze,  the   free  end  of  the  silk  thread   issuing   from  the  mouth  of 
the  pouch.      When   it   is   desired  to  remove  the  drain,  the  gauze 
strips  are  removed  and  the  jiouch   removed  by    making    traction 
upon  the  string.      Mikulicz  speaks  of  an  iodoform  gauze  drain,  and 
any  surgeon  who  has  had  considerable  experience  in  abdominaf  sur- 
gery can  testify  to  the  fact  than  when  the  Mikulicz  drain  is  called 
for  we  are  frequently  dealing  with  large  cavities   ic(|uiriiig  an  enor- 
mous amount  of  gauze.      It  is  in  such  cases  that  we  mu.st  learn  to 
fear  K)doform  gauze,  because  the  ca.ses  are  by  no  means  isolated  in 
which    a    gauze    drain    compo.sed    exclusively  of  iodoform   gauze 
ha.s  been  the  immediate  cau.se  of  death  from  iodoform  intoxication. 
This  is  particularly  liable  to  occur  in  ca.ses   in  which  the  patient's 
kidneys   are    not    functionating  properly  or  are  di.seased.      It  is  in 
44 


690  PERITONITIS. 

dealing  with  this  class  of  cases  that  the  ehmination  of  iodoform  is 
accompHshed  with  great  difficulty,  and  hence  when  accumulation 
occurs,  death  is  liable  to  follow  from  intoxication.  Again,  there  are 
persons  who  are  extremely  susceptible  to  the  local  and  general 
toxic  effects  of  iodoform.  A  very  small  quantity  of  this  substance 
may  prove  fatal  from  intoxication.  It  is,  therefore,  advisable,  in 
using  the  Mikulicz  drain,  to  limit  the  iodoform  gauze  to  an  outer 
layer  or  two  and  pack  the  pouch  with  ordinary  sterilized  gauze. 
Drainage  by  using  sterilized  wicking  has  beert  popular  in  Germany 
for  a  number  of  years,  and  in  many  cases  has  answered  an  excel- 
lent purpose.  It  has  never  found  its  way  to  any  extent  into 
America,  where  gauze  is  employed  in  preference. 

A  most  excellent  method  of  securing  capillary  drainage  has 
been  described  by  R.  T.  Morris.  To  avoid  the  danger  of  hard  and 
soft  tubes  and  of  unprotected  gauze,  he  recommends  wicks,  which 
he  employs  in  a  peculiar  way.  The  simplest  wick  consists  of  a 
little  roll  of  absorbent  bichlorid  gauze,  around  which  are  wrapped 
a  couple  of  thicknesses  of  Lister's  protective  silk.  The  gauze  pro- 
trudes a  little  from  each  end  of  the  cylinder,  and  a  few  small  fen- 
estrae  in  the  protective  silk  allow  the  serum  to  reach  the  gauze 
elsewhere.  In  certain  cases  where  injections  through  a  tube  are 
desirable,  the  soft  tube  can  be  surrounded  by  this  wick.  When  a 
large  gauze  packing  for  the  pelvis  or  abdomen  is  needed,  an  apron 
of  the  silk  can  expand  over  the  gauze  and  protect  against  intestinal 
adhesions.  This  method  of  drainage  possesses  great  advantages 
over  ordinary  tubular  and  capillary  drainage  as  heretofore  described, 
and  recommends  itself  more  especially  in  the  surgical  treatment  of 
diffuse  septic  peritonitis.  The  prolonged  contacti  of  gauze  with  a 
serous  surface  is  very  prone  to  give  rise  to  permanent  adhesions,  as 
every  clinician  knows.  In  employing  gauze  in  draining  the  perito- 
neal cavity  it  is  necessary  to  use  long  strips,  which  should  be  in- 
serted some  distance  in  different  directions  and  brought  out  at  the 
same  place  and  fastened  together  with  a  safety-pin.  Van  Hook  has 
shown  by  his  experiments  that  the  gauze  drains  more  freely  if  the 
external  ends  of  the  strips  are  left  long  and  placed  on  the  side  of 
the  pelvis  below  the  level  of  the  wound. 

Drainage  must  be  dispensed  with  as  soon  as  possible,  in  order 
to  prevent  adhesions  and  to  enable  the  surgeon  to  close  the  incision 
by  secondary  suturing,  an  important  precaution  against  the  forma- 
tion of  a  ventral  hernia.  The  strips  should  be  shortened,  and  one 
after  the  other  removed  as  the  indications  for  drainage  disappear. 

Combined  tubular  and  capillary  drainage  :  The  simultaneous 
use  of  a  tubular  and  capillary  drain  is  an  excellent  method  of  secur- 
ing drainage.  It  is  made  by  packing  loosely  a  glass  drain  of  proper 
length  and  size  with  strips  of  gauze  or  aseptic  wicking.  This  man- 
ner of  drainage  is  especially  useful  when  the  inflammatory  product 
is  serum  instead  of  pus.  It  does  away  with  the  annoyance  and 
risks  of  removing  the  transudate  at  frequent  intervals,  as  is  neces- 


AFTER-TREATMENT.  69 1 

sary  in  the  employment  of  simple  tubular  drainage.  If  it  is  the 
design  of  the  surgeon  to  resort  to  frequent  irrigation  after  the  opera- 
tion, tubular  drainage  is  necessary,  but  to  this  can  be  added  capil- 
lary drainage  by  inserting  strips  of  gauze  into  localities  that  would 
not  be  reached  by  the  irrigating  fluid. 

Inh'a-intcstinal  Saline  Injections. — The  value  of  saline  cathartics 
in  the  treatment  of  peritonitis  in  its  early  stages  not  caused  by  per- 
foration and  after  operations  for  peritonitis  is  now  generally  recog- 
nized. One  of  the  difficulties  encountered  in  the  treatment  of  such 
cases  is  the  intolerance  of  the  stomach  to  food  and  medicines.  A.  J. 
McCosh  has  succeeded  in  securing  free  catharsis  and  in  overcom- 
ing the  intestinal  paresis  after  operations  for  peritonitis  by  injecting 
into  the  intestine  saline  cathartics  in  concentrated  solution.  He 
claims  that  since  he  has  resorted  to  this  additional  procedure  his  re- 
sults have  been  greatly  improved.  Sulphate  of  magnesia  is  injected, 
through  a  hollow  needle  attached  to  a  large  aspirating  syringe,  into 
the  small  intestine,  at  a  point  in  the  jejunum  or  in  the  ileum  as  high 
up  as  possible.  A  saturated  solution  containing  from  one  to  two 
ounces  of  the  salt  is  u.sed.  The  needle  puncture  is  closed  by  a 
Lembert  suture.  This  suggestion  certainly  appears  rational  and 
should  receive  a  fair  trial  by  the  profession. 

After=treatment. — In  all  cases  of  general  septic  peritonitis  sub- 
jected to  operative  treatment  the  most  attentive  and  careful  after- 
treatment  is  essential  to  success.  All  such  patients  are  prostrated 
from  the  effects  of  the  disease  and  the  immediate  effects  of  the  opera- 
tion and  require  a  stimulating  treatment.  External  dry  heat  is  an 
important  element  in  counteracting  the  direct  effects  of  the  shock 
caused  by  the  operation  and  in  restoring  the  peripheral  circulation. 
The  distres.sing  thirst  is  quenched  most  effectually  by  the  administra- 
tion of  water  by  subcutaneous  infusion  or  rectal  enemata.  Strychnin 
and  alcoholic  .stimulants  are  best  calculated  to  increase  the  force  of 
the  heart's  action  and  the  tone  of  the  arterial  circulation.  Partial 
inversion  of  the  body  by  raising  the  foot  of  the  bed  and  autotransfu- 
sion  are  potent  means  of  inducing  cardiac  stimulation.  A  well-fitting 
abdominal  bandage  applied  firmly  exerts  a  favorable  influence  in  pre- 
venting and  diminishing  abdominal  distention.  As  long  as  nausea 
and  vomiting  persist,  main  reliance  must  be  placed  on  rectal  feeding. 
Saline  cathartics  should  be  administered  as  soon  as  the  stomach  is  in 
a  condition  to  absorb  them.  Meteorism  can  often  be  relieved  b\'  high 
turpentine  enemata  and  the  u.se  of  the  elastic  rectal  tube. 

A  number  of  cases  have  recently  been  re])ortcd  in  which  the 
serum  appears  to  have  been  of  great  value  in  the  treatment  of  sep- 
tic conditions  in  the  peritoneal  cavity  and  elsewhere.  It  is  not 
probable  that  the  .serum  treatment  will  ever  displace  the  knife  treat- 
ment of  diffu.se  general  septic  peritonitis.  Marmorek's  antistrepto- 
coccic scrum  has  proved  a  failure  in  the  treatment  of  septic  periton- 
itis. r)pium  should  be  used  with  great  caution  in  the  after-treatment, 
as  it  is  liable  to  cause  intestinal  ])aresis  and  thus  increase  the  danger 


692 


PERITONITIS. 


from  autointoxication.  If  the  peritoneal  cavity  has  been  drained 
with  gauze,  the  external  dressing  should  be  changed  as  soon  as  it 
has  become  saturated.  The  same  course  of  treatment  is  to  be  pur- 
sued if  the  combined  tubular  and  capillary  drain  has  been  used.  In 
cases  in  which  tubular  drainage  has  been  established,  the  surgeon 
usually  intends  to  follow  the  operation  by  continuous  or  periodic 
irrigation.  If  continuous  irrigation  is  decided  on,  the  normal  salt 
solution  is  the  one  usually  employed.  The  solution  should  be  used 
at  a  temperature  of  105°  F.  ;  the  current  should  be  small  and  with- 
out much  force.  The  outflow  from  the  peritoneal  cavity  should  be 
received  upon  a  rubber  blanket,  and  the  necessary  provision  made 
to  conduct  it  into  a  receptacle  near  the  patient's  bed.  This  method 
of  irrigation  recommends  itself  particularly  in  cases  of  diffuse  septic 
peritonitis.  In  suppurative  diffuse  peritonitis  periodic  flushings, 
repeated  at  intervals  of  two  or  three  hours,  will  prove  of  value  in 
removing  from  the  peritoneal  cavity  the  fluid  products  of  the  inflam- 
matory process.  The  solutions  best  adapted  for  this  purpose  are  a 
saturated  solution  of  the  acetate  of  aluminum,  a  3  to  5  per  cent, 
solution  of  boric  acid,  or  Thiersch's  solution.  Between  the  flush- 
ings the  wound  and  the  openings  of  the  drains  are  covered  with  the 
usual  hygroscopic  aseptic  dressings  to  receive  the  discharge  and  to 
prevent  secondary  mixed  infection  with  putrefactive  bacilli.  Drain- 
age, when  once  established,  should  be  suspended  gradually  and  not 
suddenly.  As  soon  as  the  peritoneal  cavity  and  the  drain  canals 
are  aseptic,  the  external  wound  should  be  sutured  to  prevent,  as 
far  as  possible,  the  subsequent  formation  of  a  ventral  hernia. 

3.  Perforative  Peritonitis. — Perforation  of  the  abdominal  wall 
or  of  any  of  the  abdominal  organs  containing  septic  material  may 
give  rise  to  general  or  circumscribed  peritonitis  ;  large  visceral  per- 
forations usually  result  in  general  septic  peritonitis  ;  small  perfora- 
tions are  preceded  by  visceral  adhesions  that  limit  the  extension  of 
the  infection  and  inflammation  and  end  in  circumscribed  peritonitis. 
Perforative  peritonitis  invariably  occurs  as  a  secondaiy  affection,  usu- 
ally in  connection  with  an  ulcerative  or  gangrenous  lesion  of  any 
part  of  the  gastro-intestinal  canal.  Perforating  ulcer  of  the  stomach, 
duodenum,  or  typhoid  or  tubercular  ulcers  of  the  ileum,  perforation, 
or  sloughing  of  the  appendix  vermiformis,  the  different  forms  of  in- 
testinal obstruction,  are  the  most  frequent  causes  of  this  well-defined 
clinical  form  of  peritonitis.  Penetrating  wounds  of  the  abdomen  with 
visceral  injury  of  the  gastro-intestinal  canal  must  be  regarded  in  the 
same  light  as  perforative  lesions  of  the  abdominal  organs  in  the  causa- 
tion of  peritonitis,  and  should  hence  be  classified  under  this  head 
from  a  bacteriologic  as  well  as  anatomicopathologic  standpoint.  Per- 
forative peritonitis  is  manifested  by  the  sudden  onset  of  the  disease, 
by  diffuse  pain  and  tenderness,  rigid  abdominal  walls,  fever,  vomit- 
ing, the  impossibility  by  inspection,  palpation,  and  auscultation  to 
ascertain  intestinal  peristalsis,  this  condition  being  almost  positive  proof 
of  intestinal  paresis  or  the  presence  of  gas  in  the  free  peritoneal  cavity. 


PERFORATING    GASTRIC    ULCER.  6q^ 

According  to  my  obsenations,  peritoneal  meteorism  in  perforative 
peritonitis  caused  b>'  appendicitis  is  rare,  while  I  have  seldom  found 
It  absent  in  perforations  of  any  other  portion  of  the  gastro-intestinal 
canal.  According  to  the  number  and  virulence  of  the  microbes  that 
hnd  their  way  into  the  peritoneal  cavity  with  the  extravasation  the 
resulting  peritonitis  is  either  diffuse  or  more  or  less  circumscribed 
1  he  colon  bacillus  is  invariably  present  in  the  inflammatory^  product' 
but  in  addition  streptococci,  staphylococci,  putrefactive  bacilli  the 
typhoid  bacillus,  or  the  bacillus  of  tuberculosis,  accordino-  to  the 
nature  of  the  primaiy  affection,  may  also  be  found.  "^ 

Perforative  peritonitis  must  be  regarded  and  treated  as  a  strictly 
surgical  disease.      The  primary  lesion  must  be  exposed  and  treated 
as  soon  as  a  diagnosis  can  be  made  and  the  necessary  measures 
applied  to  limit  the  extension  of  the  infection  and  to  prevent  death 
from   toxemia.     The  perforation    should   be   found    and    properly 
treated  before  a  general  septic  peritonitis  has  had  time  to  develop 
liiere  are  exceptions  to  this  rule  in  cases  where  the  perforation  is 
sma  1  and  the  extravasation  has  produced  a  limited  peritonitis  in  a 
locality  where  it  is  safe  to  wait  for  abscess  formation,  as  is  often  the 
case  in  the  region  of  the   gall-bladder  and   appendix  vermiformis 
Penetrating  wounds  of  the  abdomen  with  visceral  lesions  of  sufficient 
extent  to  give  rise  to  extravasation  should  be  subjected  at  once  to 
treatment  by  laparotomy.    If  at  the  time  the  operation  is  performed 
peritonitis  has  set  in,  this  must  receive  proper  attention  after  the 
visceral  wounds  ha\e  received  the  necessary  treatment 

Perforating  Gastric  Ulcer.— Perforating  ulcer  of  the  stomach  is 
found  most  frequently  on  the  anterior  wall  of  the  stomach,  near  the 
small  cur^-ature.     According  to  Brinton,  in  85  per  cent,  of  all  cases 
the  anterior  wall  of  the  .stomach  is  the  seat  of  the  perforation.      Per- 
foration in  this  locality  is  followed  more  constantly  by  diffuse  periton- 
itis than  if  the  po.sterior  wall  is  the  .seat  of  ulceration  and  perforation. 
In   75   cases   of  perforating   ulceration  of  the  anterior  wall   of  the 
stomach  collected  by  I<:ichhorst.  in  64  the  perforation  was  complete, 
whereas  in  30  ca.ses  at  the  cardiac  extremity  escape  of  contents  into 
the  peritoneal  cavity  occurred  but  1 2  times.      When  perforation  of 
the  ulcer  into  the  free  peritoneal  cavity  takes  place,  the  onset  of  the 
disease  is  always  sudden,  no  matter  what  the  antecedent  .symjjtoms 
may  have  been.      Shock  is  present  in  greater  or  less  degree.      Vom- 
iting, though  frequent,  is  not  constant.    Abdominal  pain  and  tender- 
ness increased   by  pressure  are  nearly  always  present;   abdominal 
rigidity  in  the  early  stage,  and  di.stention  later  on,  are  frequently 
noted.    The  duration  of  the  cases  varies  from  a  few  hours  to  five  days, 
mo.st  of  them  terminating  in  death  in  less  than  twenty-four  hours. 

Treatvicnt. — Mikulicz  performed  the  first  operation  for  this  con- 
dition in  1883.  The  first  successful  ca.se  was  reported  by  Kricge.  of 
Jk-rlin.  The  inci.sion  should  be  made  in  the  median  line,  from  the 
ensiform  cartilage  to  the  umbilicus,  and  enlarged  if  necessary.  y\ 
long  incision  is  required  if  the  oj^-ration  is  performed  after  peritonitis 


694 


PERITONITIS. 


has  developed.  In  such  cases  suprapubic  and  epiumbilical  drainage 
is  required  after  suturing  of  the  perforation,  and  free  flushing  of  the 
abdominal  cavity  is  indicated.  If  the  posterior  wall  is  perforated  and 
the  perforation  can  not  be  reached  in  the  usual  manner,  the  anterior 
wall  should  be  incised  and  the  perforation  closed  through  the  incision, 
after  which  the  incision  is  sutured  and  the  peritoneal  cavity  cleansed 
and  the  external  wound  closed  if  the  peritoneal  cavity  has  not  be- 
come infected.  Before  suturing  the  perforation  the  stomach  should 
be  emptied  through  a  stomach-tube  or  through  the  opening  before 
suturing  the  perforation.  It  is  not  necessary  to  excise  the  margins 
of  the  ulcer,  as  these  can  be  inverted  in  tying  the  Lembert  sutures. 
Should  the  wall  of  the  stomach  in  the  immediate  vicinity  of  the  ulcer 
present  an  unfavorable  condition  for  successful  suturing,  an  omental 
flap  or  graft  of  requisite  size  should  be  sewed  with  catgut  over  the 
line  of  suturing. 

E.  W.  Andrews  treats  the  gastric  ulcer  by  incision  of  the  wall  of 
the  stomach  in  the  direction  of  its  lumen,  and  applying  a  ligature  at 
the  base  of  the  cone,  which  answers  as  an  excellent  substitute  for 
sutures  and  greatly  simplifies  and  shortens  the  operation. 

Barling  operates  after  the  symptoms  of  shock  have  subsided. 
According  to  his  experience,  the  prognosis  is  best  if  the  operation  is 
performed  as  soon  as  possible  after  the  accident  has  occurred.  In 
nine  successful  cases  collected  by  this  author,  the  operation  was  made 
on  an  average  seven  and  three -fourth  hours  after  the  perforation 
occurred  ;  shortest  interval  three  hours,  longest  ten  hours.  In  fifteen 
cases  that  died  the  average  time  was  twenty-seven  hours ;  the 
shortest  interval  four,  the  longest  seventy,  hours.  Perforation  of  the 
posterior  wall  of  the  stomach  frequently  gives  rise  to  a  subdiaphrag- 
matic abscess,  and  when  the  disease  resulting  from  the  perforation  has 
reached  this  stage,  it  must  be  treated  in  accordance  with  the  rules 
that  will  be  laid  down  in  discussing  this  subject  later  on. 

Perforating  Ulcer  of  the  Duodenum. — Much  that  has  been  said 
concerning  perforating  ulcer  of  the  stomach  applies  to  the  same 
pathologic  condition  of  the  duodenum.  The  perforation  occurs  sud- 
denly and  frequently  without  any  marked  premonitory  symptoms 
indicative  of  the  existence  of  the  primary  disease.  The  direction  in 
which  the  extravasation  takes  place  depends  on  the  location  of  the 
ulcer.  Perforation  into  the  free  peritoneal  cavity  before  any  adhe- 
sions have  taken  place  results  in  diffuse  and  rapidly  fatal  peritonitis. 
If  perforation  takes  place  into  the  lesser  peritoneal  cavity,  circum- 
scribed suppurative  peritonitis  ensues,  which  occasionally  terminates 
in  the  formation  of  a  subdiaphragmatic  abscess. 

Treatment. — It  is  only  recently  that  peritonitis  resulting  from  this 
cause  has  been  subjected  to  operative  treatment.  Percy  Dean,  in 
1894,  performed  the  first  successful  operation.  Greig  Smith  ad- 
vises incision  over  the  seat  of  perforation — that  is,  if  the  condition  is 
suspected.  If  we  follow  this  rule,  the  incision  will  be  above  the 
umbilicus  and  through  the  right  rectus  muscle.     The  ulcer  is  usually 


PERFORATING  TYPHOID  ULCER.  6q5 

in  the  first  part,  but  may  be  in  either  of  the  other  two  portions.  In 
order  to  expose  the  lesser  peritoneal  cavity  we  must  split  the  o-astro- 
colic  omentum  in  part.  The  ulcer  is  simply  inverted,  excision  beino- 
unnecessary.      Drainage  must  always  be  provided  for. 

Perforating    Typhoid    Ulcer. — Perforation   of  a   typhoid    ulcer 
large  enough  for  extravasation  to  take  place  into  the  free  peritoneal 
cavity  is  a  fatal  accident,  death  ensuing  in  the  course  of  a  day  or  two. 
Perforation,  however,  does  not  alwa^-s  terminate  in  that  way.      Ex- 
travasation is  often  prevented  by  the  affected  part  of  the  intestinal 
wall  becoming  attached  to  an  adjoining  serous  surface,  thus  protect- 
ing the  peritoneal  cavity  against  infection.     I  have  seen  several  cases 
of  typhoid  fever  in  which,  about  the  time  that  perforation  is  most 
likely  to  occur,  circumscribed  peritonitis  set  in,  which  could  have 
been  caused  only  by  a  perforating  ulcer,  but  under  such  favorable 
conditions  that  the  patients  recovered  without  operative  intervention. 
Treatment  and  Results. — Kussmaul  was  the  first  to  perform  lapa- 
rotomy, excise,  and  suture  a  perforating  typhoid  ulcer.      The  opera- 
tion was  performed  October,  1885.      Luecke  reports  a  case  in  which 
he  performed  laparotomy  for  the  same  indication  October  22,  1885. 
A  large  perforation  was  found,  excised,  and  the  edges  sutured.'     The 
abdominal  cavity  was  washed  out  with  salicylated  water,  the  wound 
sutured,  except  a  space  left  for  a  large  tubular  drain.     The  patient 
died  in  seven  hours.      A  pint  of  fluid  with  a  fecal  odor  was  found  in 
the  pelvic  cavity.      Luecke,  in  connection  with  the  report  of  this  case, 
suggested  the  performance  of  the  operation  in  two  stages,  the  per- 
forated intestine  to  be  fastened  to  the  abdominal  wall  in  the  wound 
in  the  first,  and  the  direct  treatment  of  the  perforation  later.      In  the 
following   three   years   the  operation  was  performed   by  l^ontecou, 
Bartlett,  and  T.  G.  Morton  with  no  recoveries.      Van  Hook  reports 
3  cases  treated  by  laparotomy  and  suturing  of  the  perforation,  of  which 
I    recovered.      He  collected   19  ca.ses,  of  which  4   recovered.      He 
places  the  line  of  sutures  parallel  to  the  long  axis  of  the  bowel,  and 
flushes  the  peritoneal  cavity  with  a  thick  stream  of  .sterilized  .salt  solu- 
tion at  a  temperature  of  from  105°  to  112°  F. 

Wiggin  collected  24  ca.ses  of  perforating  typhoid  ulcer  subjected 
to  laj)arotomy,  with  6  recoveries.  If  those  cases  are  rejected  in  which 
the  diagnosis  is  somewhat  doubtful,  there  are  17  patients  with  3  re- 
coveries. The  first  successful  result  was  obtained  by  Van  Hook,  the 
.second  by  Netschajans,  the  third  by  Abbe.  J.  Price  has  recently 
reported  3  con.secutive  operations  with  as  many  recoveries,  a  surgical 
feat  which  it  will  be  difficult  to  duplicate.  I  have  performed  the 
operation  3  times  with  i  recovery.  The  feasibility  and  ju.stifiability 
of  abdominal  section  for  perforating  typhoid  ulcer  have  been  estab- 
lished, in  view  of  the  fact  that  all  the  i^atients  who  have  been 
operated  on  would  have  died  without  the  operation.  The  operation 
should  be  performed  as  .soon  as  possible  after  the  accident  has 
occurred.  The  mortality  will  always  remain  great,  owing  to  the  de- 
bilitated condition  of  the  patients  and  the  exi.stencc  of  multiple  ulcers. 


696 


PERITONITIS. 


The  incision  is  made  through  the  median  line,  between  umbiHcus  and 
pubes,  and  at  least  large  enough  to  insert  a  hand.  The  first  point 
to  be  sought  for  is  the  ileocecal  region,  when  search  is  made  for  the 
perforation  in  an  upward  direction,  replacing  the  part  of  the  bowel 
examined  so  as  to  prevent  extensive  eventration.  Excision  of  the 
ulcer  is  unnecessary,  as  its  margins  can  be  inverted  by  the  Lembert 
stitches,  which  should  be  placed  transversely  and  not  in  the  long 
axis  of  the  bowel,  as  advised  by  Van  Hook.  Should  the  serous 
surface  over  any  other  ulcer  present  indications  of  an  approaching 
perforation,  it  should  be  covered  with  an  omental  flap  or  graft  fas- 
tened in  place  with  a  few  points  of  catgut  suture.  Flushing  of  the 
abdominal  cavity  with  a  warm  physiologic  solution  of  salt,  followed 
with  Thiersch's  solution  and  free  drainage,  is  strongly  indicated  and 
should  invariably  be  carried  out.  If  the  patient  is  much  prostrated, 
Luecke's  suggestion  to  perform  the  operation  in  two  stages  should 
receive  serious  consideration.  If  the  perforation  has  resulted  in  cir- 
cumscribed suppurative  peritonitis,  incision  and  drainage  of  the  abscess 
cavity  are  indicated,  leaving  the  perforation  to  heal  spontaneously  or 
to  be  closed  by  a  subsequent  operation. 

4.  Circumscribed  Peritonitis. — A  circumscribed  peritonitis  is 
an  inflammation  of  the  peritoneum  during  which  a  greater  or  lesser 
part  of  the  peritoneal  cavity  becomes  excluded  from  the  original 
source  of  infection  by  the  formation  of  plastic  visceral,  parietal,  or 
visceral  and  parietal  adhesions.  The  complexus  of  symptoms  varies 
according  to  the  degree  of  virulence  of  the  microbic  cause,  which  only 
occasionally  is  overshadowed  by  the  primary  affection.  The  symptoms 
appear  suddenly,  or  are  preceded  by  those  incident  to  the  primary  dis- 
ease. The  severity  of  the  pain  and  the  extent  of  muscular  rigidity  and 
tenderness  will  correspond  with  the  extent  of  the  disease.  The  intensity 
of  the  general  symptoms  is  determined  more  by  the  nature  and  virulence 
of  the  microbic  cause  than  by  the  area  of  the  peritoneal  surface  in- 
volved. The  inflammatoiy  focus  may  be  limited  to  a  very  small 
space,  or  it  may  involve  the  greater  portion  of  the  peritoneal  cavity 
and  organs  which  it  contains.  The  clinical  course  and  termination 
are  determined  largely  by  the  nature  of  the  bacterial  cause,  the  an- 
atomic location  of  the  primary  starting-point,  and  nature  of  the  en- 
vironment. Localized  peritonitis  is  most  likely  to  occur  outside  of 
the  limits  of  the  small  intestine  area.  If  the  organs  adjacent  to  the 
primary  focus  of  infection  are  favorably  located  for  limitation  of  the 
process,  diffusion  is  frequently  prevented  by  the  formation  of  adhe- 
sions. This  is  especially  true  in  cases  where  the  primaiy  infection  is 
limited  by  the  existence  of  old  adhesions.  Localized  peritonitis  may 
be  confined  to  the  lesser  omental  cavity,  particularly  in  cases  of  per- 
forating ulcer  of  the  stomach  and  the  duodenum.  More  frequently 
it  is  caused  by  appendicitis  and  cecitis.  A  very  frequent  cause  of 
circumscribed  peritonitis  is  inflammation  about  the  gall-bladder, 
uterus,  Fallopian  tubes,  or  ovaries.  The  localized  form  of  periton- 
itis is  very  often  overlooked  during  life.      It  can  usually  be  detected 


ACUTE    TUBERCULAR    PERITONITIS.  69/ 

onl\'  if  a  demonstrable  swelling  forms  at  the  seat  of  inflammation. 
The  mildest  form  of  infection  gives  rise  to  fibrinoplastic  peritonitis, 
which  leaves  temporary  or  permanent  adhesions,  but  terminates  with- 
out suppuration.  Circumscribed  suppurative  inflammation  is  always 
attended  by  fibrinoplastic  peritonitis,  the  products  of  which  and  the 
viscera  which  it  inv'olves  form  the  abscess  wall.  The  microbes  that 
most  frequently  produce  fibrinoplastic  peritonitis  without  suppuration 
are  the  gonococcus  and  the  staphylococci.  Circumscribed  suppura- 
tive peritonitis  is  usually  the  result  of  infection  with  staphylococci, 
bacillus  coli  communis,  or  pneumococci.  In  fibrinoplastic  peri- 
tonitis surgical  interference  becomes  necessary  only  when  intestinal 
obstruction  is  caused  by  adhesions.  In  circumscribed  suppurative 
peritonitis  the  pus  should  be  evacuated  as  soon  as  the  disease  is 
recognized,  and,  if  possible,  by  an  extraperitoneal  route. 

Acute  Tubercular  Peritonitis. — Tubercular  peritonitis,  met  with 
in  the  majority  of  cases  in  the  circumscribed  form,  occasionally 
presents  itself  as  a  widely  diffused  acute  affection.  The  rapid  diffu- 
sion in  the  peritoneal  cavity,  through  either  the  circulation  or  by 
rupture  of  a  tubercular  abscess  or  intestinal  tubercular  ulcer  into  the 
peritoneal  cavity,  or  by  extension  from  a  tubercular  salpingitis,  occa- 
sionally gives  rise  to  a  form  of  acute  peritonitis,  characterized  as 
such  in  a  modified  way  by  the  clinical  manifestations  that  accom- 
pany it.  According  to  the  intensity  of  the  infection  or  the  degree 
of  susceptibility  of  the  patient  to  the  action  of  the  tubercle  bacillus, 
the  disease  assumes  one  of  the  following  pathologic  forms  :  ( i ) 
Tubercular  ascites ;  (2)  fibrinoplastic  peritonitis  ;  (3)  adhesive  peri- 
tonitis. Suppuration  takes  place  only  when  the  tubercular  product 
becomes  the  .seat  of  a  secondary  mixed  infection  with  pus-microbes. 
Laparotomy  is  now  a  well-established  operation  in  tubercular  peri- 
tonitis. The  exact  manner  in  which  the  operation  exerts  its  thera- 
jjeutic  influence  is  not  well  understood. 

Nannotti  and  Baciocchi  studied  the  curative  effect  of  incision  and 
drainage  for  peritoneal  tuberculo.sis  experimentally  produced  on  rab- 
bits and  dogs.  The  operation  yielded  only  temporaiy  improvement 
in  rabbits,  but  usually  resulted  in  a  permanent  cure  in  dogs.  They 
found,  soon  after  the  operation,  a  decided  local  reaction  in  the  per- 
i})hery  of  the  tubercle  nodules,  an  increased  phagocytosis,  which  in 
dogs  brought  about  absorption  of  the  tubercular  product  and  forma- 
tion of  new  connective  tissue.  Irrigation  of  the  peritoneal  cavity  did 
not  apj)ear  to  add  to  the  therapeutic  effect  of  the  operation.  Accord- 
ing to  these  investigators,  the  curative  influence  of  the  operation  is  to 
be  attributed  to  the  local  reaction  that  it  induces,  and  also  to  the  fact 
that  it  increases  the  absorptive  power  of  the  jjcritoneum.  I  have 
obtained  very  satisfactory  results  in  ca.ses  that  resisted  laparotomy 
and  drainage,  by  repeated  tap[)ings  and  injections  of  from  two  to  four 
drams  of  a  10  per  cent,  iodoform  glycerin  emulsion. 

Suppurative  Peritonitis. — Sujjpurative  peritonitis — /'.  c,  an  in- 
flammation of  the  jjcritoneum  that  results  in  the  formation  of  pus — 


698  PERITONITIS. 

is  always  more  or  less  circumscribed.  This  form  of  peritonitis  is 
most  frequent  and  is  generally  associated  with  fibrinoplastic  exuda- 
tion. The  pus  is  serous,  seropurulent,  or  may  reach  the  consistence 
of  cream,  when  it  is  usually  of  a  yellow  color.  The  accumulation 
of  pus  may  be  so  large  that  upon  opening  the  abdomen  it  may 
appear  as  though  the  entire  peritoneal  cavity  and  all  the  organs  con- 
tained within  were  implicated,  but  a  careful  examination  will  almost 
always  reveal  the  fact  that  a  large  part  of  the  peritoneal  cavity  and 
many  of  the  organs  are  shut  out  from  the  inflammatory  process  by 
plastic  adhesions.  Suppurative  peritonitis  must  therefore  be  regarded 
from  a  practical  standpoint  as  a  circumscribed  inflammation.  The 
appearance  and  character  of  the  pus  are  often  greatly  modified  by 
the  admixture  of  an  extravasation  accompanying  the  perforative 
lesion  that  produced  the  peritonitis.  If  the  pus  is  thin  and  serous, 
we  speak  of  a  seropurulent  peritonitis — it  is  a  serous  peritonitis  with 
the  formation  of  pus  in  sufficient  quantity  to  render  the  serum  more 
or  less  turbid.  This  subvariety  of  suppurative  peritonitis  is  without 
exception  in  combination  with  fibrinous  exudations  that  tend  to  limit 
the  extension  of  the  infective  process.  Sedimentation  of  the  solid 
constituents  takes  place,  so  that  the  fluid  contains  more  of  the  solid 
matter  in  the  most  dependent  portion  of  the  affected  district. 

Fibrinoplastic  Peritonitis. — A  very  frequent  form  of  circum- 
scribed peritonitis  is  the  one  in  which  the  inflammatoiy  exudate  is 
composed  largely  of  fibrin — fibrinoplastic  peritonitis.  It  is  usually 
a  secondary  process  following  a  primary  affection  of  one  of  the  ab- 
dominal or  pelvic  organs,  and  denotes  a  mild  form  of  infection,  the 
extension  of  which  becomes  limited  by  firm  adhesions.  The  inflam- 
mation results  in  plastic  exudation  with  little  or  no  effusion.  The 
character  of  the  exudate  depends  on  the  intensity  and  quality  of  the 
bacterial  cause.  The  exudation  is  often  so  copious  that  it  has  been 
mistaken  for  malignant  disease.  The  distinguishing  features  of  this 
form  of  peritonitis  from  abdominal  tumor  are  less  circumscribed  out- 
line, the  lesser  resistance  offered,  the  more  regular  surface,  and  the 
fact  that  ascitic  fluid  is  not  bloody,  but  serous  or  seropurulent.  The 
exudation  in  the  course  of  time  contracts  and  results  in  strong  bands 
of  adhesion  that  frequently  flex  and  distort  the  organs  to  which  they 
are  attached,  thus  giving  rise  to  another  term,  peritonitis  deformajis. 

Treatment. — The  surgical  treatment  of  circumscribed  peritonitis 
by  abdominal  section  has  yielded  very  encouraging  results.  In  many 
of  these  cases  the  surgeon  is  able  to  reach  the  abscess  and  gain  access 
to  the  primary  lesion  without  invading  the  peritoneal  cavity.  In  such 
instances  the  operation  is  an  oncotomy,  and  should  be  distinguished 
from  the  operation  in  which  the  free  peritoneal  cavity  must  be  in- 
vaded to  reach  the  pus  cavity,  which  is  then  an  abdominal  section  in 
the  sense  in  which  this  expression  is  used  in  surgical  language.  The 
extraperitoneal  route  is  the  operation  of  choice  in  all  cases  in  which 
the  abscess  cavity  can  be  safely  reached  and  efficiently  drained  by 
this  method.    In  circumscribed  accumulations  of  pus  in  the  peritoneal 


TREATMENT.  699 

cavity,  in  which  the  seat  of  the  disease  must  be  reached  through  the 
free  abdominal  cavity,  the  safest  course  to  pursue  is  to  perform  the 
operation  in  two  stages.  The  first  operation  then  consists  in  sutur- 
ing the  parietal  peritoneum  to  the  wall  of  the  abscess  cavity,  sutur- 
ing the  abdominal  incision,  with  the  exception  of  a  space  large 
enough  to  incise  and  drain  the  abscess  cavity  later.  This  space  is 
packed  with  iodoform  gauze,  and  two  or  three  days  later  the  abscess 
is  incised  and  drained.  If  the  symptoms  are  urgent  and  the  opera- 
tion must  be  completed,  the  contents  of  the  abscess  cavity  should  be 
removed  by  aspiration,  after  which  the  suturing  can  be  more  thor- 
oughly done,  when  the  abscess  can  be  incised  and  drained  with  less 
risk  of  infecting  the  peritoneal  cavity  than  without  preliminary  evac- 
uation by  the  use  of  the  aspirator.  These  methods  of  treatment  are 
especially  applicable  for  single  pus  cavities.  If  the  disease  is  more 
diffuse,  involving  a  number  of  abdominal  organs,  and  the  abdominal 
incision  reaches  at  once  the  infected  territory,  pus,  wherever  found, 
must  be  removed  by  flushing  or  by  mopping  with  a  soft  sponge. 
In  fibrinoplastic  peritonitis  without  suppuration  no  attempt  should 
be  made  to  tear  the  adhesions  unless  they  have  caused  intestinal 
obstruction,  when  the  new  surfaces  are  dusted  with  aristol,  which, 
as  has  been  shown  by  the  experiments  and  clinical  observations  of 
R.  T.  Morris,  is  the  most  efficient  way  to  prevent  recurrence  of  the 
adhesions. 

Witzel  admits  that  in  cases  of  peritoneal  sepsis,  the  most  acute 
and  gravest  form  of  infection,  surgical  treatment  is  of  no  avail.  In 
general  and  circumscribed  suppurative  peritonitis  operative  treatment 
is  indicated.  Eventration  and  removal  of  the  pus  with  sponges  are 
not  permissible,  as  animals  thus  treated  invariably  died.  Experi- 
ments on  animals  as  well  as  clinical  observation  satisfied  Witzel  that 
multiple  incisions,  drainage,  and  irrigation  with  salt  solution  proved 
successful  in  thoroughly  cleansing  the  peritoneal  cavity  without 
causing  shock. 

Mikulicz  advises  that  in  progressive  fibropurulent  peritcMiitis  the 
adhesions  should  not  be  disturbed,  and  each  abscess  should  be 
evacuated  .separately  in  order  to  prevent  fresh  infection  from  tiie 
liberated  contents  of  these  encapsulated  foci  of  infection.  In  one 
case  six  intraperitoneal  abscesses  were  evacuated,  through  as  many 
incisions,  at  four  consecutive  opeiations.  The  diagnostic  indica- 
tions of  such  abscesses  are  increased  resistance,  tenderness,  tlull- 
ness,  and  elevated  temperature.  In  cases  of  doubt  an  exploratory 
puncture  should  be  made.  The  abscess  cavities  should  be  drained 
with  iodoform  gauze.  Some  surgeons  pursue  a  more  aggressive 
course  and  are  not  content  in  removing  the  fluid  pathologic  product, 
Ijut  aim  to  remove  at  the  same  time  the  fibrinous  exudate.  At  the 
meeting  of  the  French  Surgical  Congress  Demons  made  a  strong  plea 
in  favor  of  early  operative  intervention  and  the  removal  of  fibrinous 
deposits.  In  1883  he  had  under  his  care  a  woman  suffering  from 
suppurative   peritonitis   following   suppuration   of  an    ovarian  cyst. 


yOO  PERITONITIS. 

Her  condition  at  the  time  of  operation  was  critical.  He  opened 
the  abdomen,  evacuated  the  pus,  removed  the  cyst,  and  with  a 
rough  sponge  and  blade  of  a  knife  scraped  the  entire  surface  of  the 
intestine  ;  a  most  satisfactory  recovery  followed.  He  deemed  it 
advisable  to  scrape  the  inflamed  surfaces,  as  being  more  efficacious 
and  affording  less  risk  of  missing  portions  of  the  exudates.  In  a 
similar  case  he  assisted  Denuce  in  performing  this  radical  method 
of  cleansing,  and  the  patient  rapidly  recovered.  There  are  few  sur- 
geons who  would  to-day  follow  his  example.  Adhesions  tend  to 
limit  the  infective  process,  and  should  be  interfered  with  as  little  as 
possible  in  the  search  and  liberation  of  pus. 

Korte  saved  six  out  of  nineteen  cases  of  acute  general  suppura- 
tive peritonitis  treated  by  abdominal  section.  All  cases  without  ad- 
hesions and  peritoneal  sepsis  died,  also  all  cases  operated  upon  after 
the  fourth  day.  He  cautions  not  to  separate  adhesions,  and  is  con- 
tent to  evacuate  the  pus  and  to  establish  drainage.  The  closure 
of  perforations  should  not  be  attempted  unless  it  can  be  done  with- 
out additional  risk. 

5.  Hematogenous  Peritonitis.  —  The  existence  of  primary 
peritonitis  without  an  antecedent  intra-abdominal  direct  source  of  in- 
fection is  looked  upon  with  suspicion  by  most  modern  pathologists 
and  surgeons.  Idiopathic  peritonitis,  so  called,  or  hematogenous 
peritonitis,  does  occur,  but  is  much  more  rare  than  similar  affections 
of  the  pleura  and  pericardium.  As  a  primary  affection,  peritonitis  is 
found  most  frequently  in  females  during  or  soon  after  menstruation. 
It  is  probable  that  the  pyogenic  bacteria  multiply  in  the  blood  which 
accumulates  in  the  uterus,  and  reach  the  peritoneal  cavity  through 
the  Fallopian  tubes.  As  peritonitis  is  always  caused  by  bacteria  of 
some  kind,  a  peritonitis  that  develops  independently  of  a  local  source 
of  infection  is  the  result  of  an  infection  through  the  blood,  and  should 
be  called  hematogenous  or  metastatic  peritonitis.  It  has  been 
observed  in  connection  with  nephritis,  pyemia,  rheumatic  arthritis, 
and  acute  exanthematous  diseases.  In  the  absence  of  even  a  distant 
focus  of  infection  it  is  plausible  to  assume  that  peritonitis  in  very  rare 
cases  is  caused  by  the  localization  of  pus-microbes  derived  from  the 
circulating  blood  in  some  part  of  the  peritoneum  prepared  for  their 
reception  and  growth  by  some  antecedent  disease  or  injury.  In 
primary  peritonitis  the  disease  is  not  preceded  by  any  symptoms 
that  would  suggest  the  existence  of  an  antecedent  disease  or  injury. 
Hematogenous  peritonitis  assumes  different  pathologic  types,  re- 
sembling in  this  respect  peritonitis  produced  b}'  direct  local  causes. 

Treati7ient. — The  surgical  treatment  must  be  guided  by  the  loca- 
tion and  extent  of  the  disease,  the  existence  or  absence  of  complica- 
tions, and  the  pathologic  t3^pe  the  disease  presents  at  the  time  of 
operation.  The  absence  of  primary  visceral  disease  of  any  of  the 
abdominal  organs  is  a  favorable  item  in  the  prognosis  and  in  the 
technic  of  the  operation  to  be  performed  in  the  surgical  treatment  of 
this  form  of  peritonitis. 


VISCERAL    PERITONITIS.  7OI 

6.  Visceral  Peritonitis. — A  localized  peritonitis  that  can  be 
brought  into  direct  etiologic  connection  with  the  organ  primarily 
affected  is  expressed  by  a  compound  word,  with  the  prefix  peri-  and 
the  noun  used  to  indicate  the  organ  primarily  affected  in  a  state  of 
inflammation.  The  inflammator\'  process  is  seldom  limited  to  a 
single  organ,  as  during  the  course  of  the  disease  adjacent  organs  or 
the  parietal  peritoneum  will  surely  become  involved.  The  nomencla- 
ture of  visceral  peritonitis  is  a  lengthy  one,  as  it  includes  all  the  ab- 
dominal and  pehic  organs  from  which,  when  the  seat  of  a  suppura- 
ti\e  inflammation,  may  come  the  primary  starting-point  of  an  attack 
of  localized  or  diffuse  peritonitis.  The  mesentery  and  omentum  are 
modified  forms  of  the  peritoneum,  and  when  the  seat  of  inflammation, 
we  speak  of  a  mesenteritis  and  epiploitis.  In  inflammatory'  and  trau- 
matic affections  of  the  abdominal  walls  and  the  abdominal  and  pelvic 
viscera,  plastic  inflammation  of  the  omentum  frequently  constitutes  the 
safeguard  against  infection  of  the  general  peritoneal  cavity  by  firmly 
attaching  the  omentum  over  a  threatened  perforation  or  visceral 
or  parietal  wound,  thus  affording  protection  against  infection  from 
within  and  without.  On  the  other  hand,  such  adhesions  between 
the  different  abdominal  viscera  and  the  viscera  and  an\' portion  of  the 
abdominal  wall  are  often  transformed  into  firm  bands  of  adhesions 
which  later  on  so  frequently  become  a  direct  cause  of  intestinal 
obstruction.  The  surgeon  to-day  imitates  nature's  process  and  makes 
use  of  the  omentum  in  covering  denuded  surfaces  or  in  suturing  tis- 
sues of  doubtful  resistance,  and  in  covering  surfaces  of  the  gastro- 
intestinal canal  the  seat  of  a  threatened  perforation.  In  visceral  peri- 
tonitis the  primary  disease  frequently  furnishes  the  special  indication  for 
which  the  operation  is  performed.  Inflammation  of  the  gall-bladder 
often  gives  rise  to  inflammation  of  the  serous  investment  of  a  number 
of  adjacent  organs,  resulting  in  succession  in  pericystitis,  epiploitis, 
perigastritis,  perihepatitis,  and  perienteritis.  The  removal  of  the 
original  cause  which  provoked  the  primary  di.sease  furnishes  the  main 
indication  in  the  treatment  of   such  extensive  pathologic  indications. 

The  surgical  treatment  of  appendicitis  and  its  various  complications 
is  not  well  settled  at  the  present  time.  Some  surgeons  advise  opera- 
tion in  all  ca.ses  in  which  a  diagnosis  of  appendicitis  can  be  made, 
regardless  of  the  nature  of  the  di.sease  and  the  character  of  its  compli- 
cations. The  more  conservative  clement  of  the  profession  limits  the 
u.se  of  the  knife  to  cases  in  which  there  are  positive  indications  for 
surgical  interference.  I  re.sortto  operation  in  all  ca.ses,  during  a  first 
attack,  when  the  sxmptoms  point  to  perforation  or  gangrene  of  the 
appendix.  The  sooner  the  operation  is  undertaken  under  such  cir- 
cumstances, the  better  are  the  results.  The  ap])endix  should  only 
be  sought  for  and  removed  if  pus  is  found  in  the  iliac  fossa,  when 
this  can  be  done  without  a  material  increase  in  the  immediate  risks 
of  the  operation,  otherwi.se  the  treatment  by  incision  and  drainage 
will  yield  the  best  results.  In  mild  ca.ses  of  appendicitis  from  80  to 
90  per  cent,  recover  under  apjjropriatc   medical   treatment,  and   in  a 


702 


PERITONITIS. 


fair  percentage  of  cases  the  disease  does  not  return.  The  gravest 
cases  are  those  in  which  the  affection  of  the  appendix  is  followed  by 
diffuse  peritonitis.  In  the  treatment  of  this  class  of  cases  nearly  all 
surgeons  are  fully  in  accord  with  the  rules  laid  down  by  McBurney. 
This  surgeon  reports  twenty-four  cases  of  diffuse  peritonitis  caused 
by  appendicitis  treated  by  abdominal  section,  of  which  number  four- 
teen recovered.  He  prefers  glass  tubes  to  rubber  drains.  The  glass 
tube  is  loosely  packed  with  sterile  gauze  and  inserted  to  the  floor  of 
the  pelvis.  He  irrigates  with  a  hot  sterile  salt  solution.  The  incision, 
four  to  six  inches  in  length,  is  made  from  a  point  near  the  anterior 
superior  spine  of  the  iHum,  following  the  direction  of  Poupart's  liga- 
ment, and  about  an  inch  above  it.  Adhesions  are  interfered  with  as 
little  as  possible.  Collections  of  pus  or  seropurulent  fluid  are  searched 
for  and  evacuated.  After  removal  of  pus  Avith  sponges  irrigation  is 
practised.  If  fluid  is  found  outside  of  the  pelvis,  strips  of  iodoform 
gauze  are  used  to  drain  the  different  spaces.  At  the  end  of  from 
twenty-four  to  thirty -six  hours  the  glass  drain  is  removed  and  a  strip 
of  gauze  inserted  in  its  place.  If  the  clinical  history  reveals  the  fact 
that  during  the  first  or  any  subsequent  attack  an  abscess  in  the  vicin- 
ity of  the  appendix  has  ruptured  into  the  cecum,  I  should  hesitate 
to  recommend  an  operation,  as  such  cases  usually  recover  spontane- 
ously in  the  course  of  time,  while  an  operation  for  such  a  condition 
is  attended  by  many  and  serious  risks.  I  have  operated  in  four 
cases,  removing  that  part  of  the  appendix  which  still  remained  and 
suturing  the  opening  in  the  cecum ;  two  of  these  cases  recovered 
and  two  died  of  septic  peritonitis  within  three  days  after  the  operation. 
In  relapsing  appendicitis  an  operation  is  indicated,  particularly  in  cases 
in  which  the  attacks  set  in  at  short  intervals  and  with  gradually  in- 
creasing intensity. 

In  peritonitis  resulting  from  infective  lesions  of  the  female  internal 
genital  organs, — the  uterus,  ovaries,  and  Fallopian  tubes, — the  organ 
primarily  affected  and  the  resulting  intraperitoneal  abscess  can  often 
be  reached  more  safely  by  a  vaginal  than  by  an  abdominal  operation. 
Occasionally  the  combined  operation  will  afford  greater  safety,  more 
complete  removal  of  the  infected  tissues  and  organs,  and  more  effi- 
cient drainage. 

7.  Pelvic  Peritonitis. — Pelvic  peritonitis  is  seldom  met  with  in 
the  male.  It  is  a  form  of  peritonitis  in  which  the  female  pelvic  organs 
are  the  primary  starting-point  of  infection,  with  extension  to  the  per- 
itoneum, through  either  the  Fallopian  tubes  or  the  lymphatics  of  the 
uterus  or  its  adnexa.  It  is  caused  most  frequently  by  gonorrheal  or 
puerperal  infection,  or  develops  after  instrumental  examination  of  the 
interior  of  the  uterus  or  operations  upon  this  organ.  In  pyogenic 
infection  the  inflammation  may  become  diffuse,  and  if  circumscribed, 
usually  leads  to  the  formation  of  parametritic  or  intraperitoneal  ab- 
scesses, or  pus-formation  takes  place  in  both  of  these  localities.  In 
the  peritoneal  cavity  the  gonococcus  produces  a  plastic  peritonitis, 
and  sometimes  localized  suppuration.      Salpingoperitonitis  and  more 


PUERPERAL    PERITONITIS.  7O3 

diffuse  pelvic  peritonitis  are  most  frequently  caused  by  gonococcus 
infection.  Ceppi  reported  the  first  case  of  laparotomy  for  gonorrheal 
peritonitis.  Gonococci  were  found  in  the  pus-cells.  The  patient 
recovered.  Abdominal  section  is  seldom  performed  for  gonorrheal 
peritonitis  during  the  acute  stage.  Opening  of  the  abdominal  cavity 
by  this  route  is  usually  reserved  for  the  removal  of  the  remote  con- 
sequences of  the  disease,  and  the  operation  usually  includes  the 
removal  of  the  adnexa  on  one  or  both  sides.  An  early  incision 
through  the  vaginal  roof  into  the  culdesac  of  Douglas  in  the  treat- 
ment of  pelvic  peritonitis,  so  strongly  urged  and  frequently  practised 
by  Henrotin,  is  a  rational  procedure  and  frequently  succeeds  in  pre- 
venting the  extcn.sion  of  the  infection  and  the  occurrence  of  serious 
remote  complications.  I  have  in  several  in.stances  incised  and  drained 
the  Fallopian  tube  through  such  an  incision,  and  in  this  way  pre- 
vented further  leakage  from  the  tube  into  the  peritoneal  cavity,  and 
thus  directly  cut  off  additional  supply  of  infectious  material.  The 
treatment  of  large  parametritic  abscesses  extending  to  the  brim  of 
the  pelvis  and  above  it,  by  making  an  extraperitoneal  incision  the 
same  as  is  resorted  to  in  ligating  the  external  iliac  artery,  a  proce- 
dure advocated  by  Pozzi,  is  preferable  to  a  transperitoneal  operation 
in  all  cases  in  which  the  abscess  can  be  reached  by  this  route. 

Birnbaum  advises,  in  puerperal  sepsis  in  which  a  pelvic  exudate 
has  been  thrown  out,  if  continued  high  fever  persi-st,  drainage  of  the 
abscess  as  required.  When  fluctuation  is  detected,  an  incision  is  made 
from  one  to  two  centimeters  above  Poupart's  ligament,  and  from  two 
to  three  centimeters  from  the  anterior  superior  iliac  .spine.  When 
fluctuation  is  not  positive,  exploratory  puncture  is  recommended  ; 
vaginal  exploration  and  incision  are  indicated  when  the  abscess  is 
located  lower  down  in  the  pelvis.  We  shall  hear  less  of  intestinal, 
vesical,  and  rectal  fistula  in  the  future  as  the  remote  results  of  pelvic 
peritonitis  or  parametritic  abscesses,  so  soon  as  the  profes.sion  recog- 
nizes fully  the  importance  and  necessity  of  timely  operative  interfer- 
ence. 

8.  Puerperal  Peritonitis. — I^y  the  term  puerperal  peritonitis 
is  understood  a  progressive  inflammation  of  the  peritoneum  occurring 
in  con.sequence  of  an  extension  of  an  infection  from  any  part  of  the 
genital  tract  in  puerperal  women  after  delivery  or  abortion.  The 
infection  usually  takes  place  through  the  lymphatics,  which  in  the 
majority  of  cases  terminates  in  diffu.se  septic  peritonitis.  In  some 
instances  the  disease  remains  limited  to  the  pelvic  organs  and  their 
serous  investment,  when  abscess  formation,  intraperitoneal  and  extra- 
peritoneal, is  very  likely  to  occur.  The  infection  in  such  compara- 
tively mild  forms  of  puerperal  sepsis  is  usually  caused  by  the  different 
varieties  of  the  .staphylocfjccus,  while  the  diffuse  septic  puerperal  per- 
itonitis is  nearly  always  produced  by  the  .streptococcus. 

Treatment. — The  treatment  of  the  localized  form  of  puerperal 
peritonitis  is  the  .same  as  that  advi.scd  in  circumscribed  peritonitis 
resulting  from  other  cau.ses.      The  foudroyant  form  of  puerperal  sepsis 


704 


PERITONITIS. 


proves  fatal  in  spite  of  the  most  energetic  medical  and  surgical  treat- 
ment. The  use  of  the  antistreptococcus  serum  may  prove  of  great 
value,  and  should  receive  an  early  and  a  fair  trial.  It  has  been  sug- 
gested that  early  removal  of  the  infected  uterus  would  prevent  the 
extension  of  the  disease  to  the  peritoneum  and  death  from  sepsis. 
A  number  of  vaginal  hysterectomies  have  beeen  performed  for  this 
indication,  but,  on  the  whole,  the  results  have  not  been  encourag- 
ing. It  is  exceedingly  difficult,  and  in  many  cases  absolutely  im- 
possible, to  make  a  sufficiently  early  and  positive  diagnosis  to  war- 
rant so  grave  and  mutilating  an  operation  as  a  timely  and  life-saving 
measure.  If  the  uterus  is  removed  after  general  septic  peritonitis 
has  developed,  the  operation  is  performed  too  late,  and  death  from 
shock  and  sepsis  is  the  rule.  Professor  von  Winckel  is  not  in  favor 
of  resorting  at  once  to  the  removal  of  the  uterus  and  adnexa  by  the 
vaginal  route.  In  cases  in  which  the  Douglas  culdesac  is  prominent 
in  the  vagina  he  recommends  a  broad  and  free  incision  behind  the 
uterus.  If  the  inflammatory  product  is  not  within  safe  reach  of  a 
vaginal  incision,  he  advises  abdominal  section.  He  is  in  favor  of 
vaginal  hysterectomy  only  in  cases  in  which  a  double  parametritis 
sets  in  after  such  a  procedure. 

9.  Subdiaphragmatic  Peritonitis. — A  peritonitis  limited  to  the 
under  surface  of  the  diaphragm  and  any  of  the  adjacent  abdominal 
organs  is  called  subdiaphragmatic  peritonitis.  If  the  inflammation 
remain  limited  and  life  is  sufficiently  prolonged,  it  usually  terminates 
in  the  formation  of  a  subdiaphragmatic  or  subphrenic  abscess.  Per- 
forating ulcer  of  the  stomach  and  duodenum  and  abscess  of  the 
spleen  and  liver  are  the  most  frequent  affections  that  precede  sub- 
diaphragmatic peritonitis.  Maydl  has  written  the  most  complete 
treatise  on  subphrenic  abscesses,  dividing  them  into  twelve  groups 
according  to  their  location  and  the  organ  from  which  they  have 
their  starting-point.  The  diagnosis  is  usually  difficult,  and  Maydl 
recommends  the  exploring  needle  very  strongly  as  an  important 
diagnostic  resource.  The  abscess  often  ruptures  in  the  pleural 
cavity,  through  which  it  is  most  frequently  reached  ;  the  pleural  cavity 
is  sometimes  found  obliterated  when  the  puncture  and  incision  are 
made  through  the  diaphragm.  In  cases  of  empyema  of  the  pleural 
cavity  the  possible  existence  of  a  subphrenic  abscess  must  be  kept 
in  mind. 

Witthauer  reports  two  cases  of  subphrenic  abscess  caused  by 
perforation  of  the  stomach  that  terminated  fatally  without  operation. 
In  the  first  case  carcinoma  of  the  stomach  was  diagnosticated,  in  the 
second  the  diagnosis  was  first  made  of  perforating  ulcer  of  the 
stomach,  but  was  later  doubted,  as  the  usual  symptoms  of  per- 
itonitis did  not  appear.  A  similar  case  is  reported  by  Schlesinger. 
Trojanow  reports  a  case  of  subphrenic  abscess  that  had  its  starting- 
point  in  a  splenic  infarct  that  occurred  during  an  attack  of  typhoid 
fever.  He  resected  the  tenth  rib  between  the  axillary  line  and 
scapula,  found  the  pleural  cavity  at  that  point  obliterated,  and   at 


APPENDICITIS.  -Q- 


once  incised  the  diaphragm  and  opened  and  drained  the  abscess   in 
he  contents   of  which   fragments  of  necrosed   splenic   tissue  were 
lound.      In  cases  in  which  the  pleural  cavity  is  not  found  obliterated 
he  advises  sutunng  of  the  pleura  to  the  diaphragm  before  opening 
the  abscess.      A  valuable  contributicni   to  the  statistics  and  surcrery 
of  subphrenic  abscesses  has  recently  been  made  by  C.  Beck  of  New 
\  ork.      He  reports  fixe  cases  treated  successfully  by  operative  inter- 
lerence.      Rib  resection  and  opening   of  the  pleural    cavity  usually 
become  necessary  as  preliminary  steps  in  opening  a  subphrenic  ab- 
scess.    Accurate  location  of  the  abscess  and  a  positive  diagnosis  are 
made  by  exploratory-  puncture.      As  perforating  ulcer  of  the  stom- 
ach IS  the  most  frequent  cause,  subphrenic  abscesses  are  more  fre- 
quently located  on  the  left  than  on  the  right  side.      Occasionalh-  a 
spontaneous  cure  occurs  by  perforation  of  the  abscess  into  a  liollow 
adjacent  organ.      Maydl  has  shown  that  out  of  104  cases  not  oper- 
ated on  only  6  recovered,  while  out  of  18  cases  operated   on  only 
II  per  cent.  died.      The  satisfactory  results  of  the  operation  furnish 
the  most  conclusive  proof   regarding  its  nccessit^'  an.d  life-savin- 
value.  '  *> 


CHAPTER    XVHI. 

APPENDICITIS. 

Appendicitis,  or  inflammation  of  the  appendix  vermiformis  is 
now  a  well-recognized  surgical  affection,  and  is  regarded  as  the 
primary  lesion  in  the  causation  of  the  numerous  pathologic  and 
clinical  forms  of  peritonitis  in  the  ileocecal  region,  formerly  de- 
scribed as  typhlitis,  perityphlitis,  paratyphlitis,  and  appendicular 
pentonitis.  Kuster  has  recently  proposed  the  term  cpitvphliti^  for 
appendicitis,  but  the  latter  word  has  gained  so  firm  a  foothold  in 
medical  literature  that  it  will  in  all  probability  remain.  According 
to  the  pathologic  conditions  presented  by  the  di.sea.sed  organ,  wS 
speak  of  catarrhal,  ulcerative,  obliterating,  perforative,  and  gangren- 
ous or  sloughing  appendicitis. 

The  successful  surgical  treatment  of  j^eritonitis  cau.sed  by  infec- 
tive lesions  of  the  appendix  vermiformis  constitutes  the  mo.st  brilliant 
chai>tcr  of  modern  aggres.sive  surgery.  The  surgeons  have  taught 
physicians,  by  scientific  research  as  well  as  by  lessons  learned  from 
clinical  experience,  tiiat  peritonitis,  in  the  majority  of  ca.ses,  is  a  .sec- 
ondary aflbction,  and  that  its  successful  treatment  depends  largely 
upon  the  detection  and  removal  of  the  primary  cau.se.  The  present 
large  amount  of  knowledge  concerning  appendicitis  and  its  compli- 
cations is  largely  the  result  of  the  work  of  American  surgeons.  The 
European  surgeons  arc  slow  in  accepting  the  teachings  and  i)ractice 
as  developed  and  promulgated  in  this  country,  but  in  the  near  future 
4<; 


7o6 


APPENDICITIS. 


they  will  have  to  submit  to  the  most  convincing  proof — the  results 
of  clinical  experience.  During  the  last  ten  years  so  much  literature 
on  the  surgical  treatment  of  inflammatory  affections  of  the  appendix 
has  accumulated  that  this  subject  has  become  somewhat  threadbare 
and  confusing.  For  a  number  of  years  it  was  customary  for  a  cer- 
tain class  of  abdominal  surgeons  to  report  the  result  of  their  annual 
work  on  ovariotomy  ;  then  it  became  the  fashion  to  give  the  statistics 
of  tubal  surgery  ;  but  at  the  present  time  the  appendix  vermiformis  is 
the  favorite  topic  of  discussion,  and  to  it  is  assigned  a  liberal  space 
in  the  medical  press  and  the  programs  of  the  medical  societies,  both 
large  and  small. 

It  would  be  more  profitable  in  the  future  for  this  department  of 
abdominal  surgery  to  write  less  concerning  individual  experience, 
and  elaborate  more  thoroughly  upon  a  pathologic  basis  the  con- 
ditions that  demand  surgical  interference.  The  surgeon  must  bring- 
more  convincing  proof  than  the  simple  recovery  from  the  operation 
— viz.,  the  reasons  for  the  necessity  of  operative  intervention — in 
order  to  convince  the  mass  of  the  profession  of  the  correctness  of  the 
ground  taken  by  a  number  of  surgeons,  that  the  appendix  should  in- 
variably be  removed  when  it  is  the  seat  of  an  infective  lesion.  There 
are  exceptions  to  nearly  all  rules,  and  the  surgery  of  the  appendix 
vermiformis  has  not  advanced  sufficiently  to  enable  us  to  lay  down 
fixed  rules  when  and  when  not  to  operate.  Pelvic  surgery  has  been 
degraded  by  the  modern  /?^r(9r  operatkms,  and  the  same  fate  threatens 
the  surgery  of  the  appendix.  The  conscientious  surgeon  must  bring 
his  work  into  consonance  with  the  pathologic  conditions  that  he  is 
expected  to  correct  or  remove. 

Size,  Location,  and  Blood  Supply  of  the  Appendix. — Abnor- 
malities in  the  size,  location,  and  blood  supply  of  the  appendix  have 
unquestionably  an  important  bearing  on  the  etiology  of  inflammation 
of  this  organ.  Infective  processes  undoubtedly  not  infrequently 
extend  from  the  appendix  to  the  cecum,  and  from  the  cecum  to 
the  appendix,  in  the  course  of  the  vascular  connection.  If  the  ap- 
pendix is  flexed  by  displacement  of  any  kind,  the  mechanical  ob- 
struction incident  to  such  malposition  would  furnish  a  strong  pre- 
disposition to  appendicitis.  Partial  or  total  gangrene  is  often  the  re- 
sult of  thrombosis  of  the  principal  artery  or  vein,  caused  by  the 
infective  process.  At  my  request.  Dr.  C.  A.  Parker,  Demonstrator 
of  Anatomy  in  Rush  Medical  College,  made  some  very  interesting 
observations  on  the  variations  in  size,  location,  and  blood  supply  of 
the  appendix.      The  following  is  a  brief  report  of  his  investigations  : 

"Observations   on  the  Appendix  Vermiformis  in  the  Dissecting  Room  of 
Rush    Medical    College,    Autumn  and  Winter  Quarters,    Session    1899 

AND    1900. 

"  Number  observed  70—59  white,  il  black  ;  males  56—51  white,  5  black  ;  females 
14 — 8  white,  6  black. 

"  Average  length  of  all,  3.67  inches— white  3.61,  black  4  ;  males  3.86— white  3.72, 
black  5^  ;  females  2.9 — white  2.8,  black  3. 


ETIOLOGY.  707 

"  Longest  male,  7  inches,  black  ;  6  inches,  white  ;  female,  4^  black;  3^  inches 
white. 

"Shortest  male,  white  i^:^  inches;  black  ^'i  inches;  female,  white  l^^  inches; 
black  ^  inch. 

"  Number  of  mesenteriola  observed,  65 — 55  white,  10  black  ;  males  54 — 49  white,  5 
black  ;   females  1 1 — 6  white,  5  black. 

'•Number  with  mesentery  extending  the  whole  length  of  the  appendix,  44 — 37 
white,  7  black  ;   males  36 — 32  white,  4  black  ;   females  8 — 5  white,  3  black. 

"Number  of  mesenteriola  extending  one-half  the  length  or  more,  but  not  the  whole 
length,  20 — 18  white,  2  black;  males  18 — 17  white,  I  black;  females  2 — i  black,  i 
white. 

"  Number  with  no  mesentery,  i,  female,  black,  appendix  3^'  inch  long. 

"Percentage  of  mesenteriola  extending  the  whole  length  6^ j4  per  cent. — white  67 
per  cent.  ;  black  70  per  cent.  ;  males  66^  per  cent. — white  65  per  cent.,  black  80  per 
cent.  ;  females  73  per  cent. — white  83  per  cent.,  black  60  per  cent. 

"  Position  of  Appendix. — Number  of  cases  observed,  70 — 59  white,  II  black  ;  males 
56 — 51  white,  5  black  ;  females  14 — 8  white,  6  black. 

"  Downward  and  inward  from  cecum,  as  follows  :  57  cases,  or  81  J[^  per  cent. 

"  («)  Cecum  in  normal  position  and  ap- 
pendix extending  to  brim  of  pelvis 
and  over  it  into  cavity,       .         .        .    .    40     "        "57  " 

"  {b)  Cecum  normal,  with  appendix  not  ex- 
tending to  pelvis,  but  curled  to  right  or 
left  and  lying  more  or  less  behind 
cecum, 7      "       "10  " 

"  {c)  Cecum  near  crest  of  ilium  and  ap- 
pendix extending  downward  and  in- 
ward over  iliacus,  reaching  pelvis  only 
where  very  long  (this  includes  one  |^ 
inch  long  that  is  not  put  in  first  be- 
cause it  did  not  reach  the  pelvic  brim),       6     "        "9  " 

"(rt')  Cecum  in  pelvis,      ...  .    .       3     "        "     4  " 

"  {/)  Cecum  in  scrotum  in  right  oblique  in- 
guinal hernia  and  appendix  at  lower 
end,  also  included  in  hernia,     ....       lease,    "       i2       " 

"  Upward  behind  the  cecum,  13  cases,  or  l8j4  per  cent.,  as  follows  : 

"  (<z)  Cecum  in  normal  position, 9  cases,  or  13      per  cent. 

"  I.   Toward  right  side, 7     "        "  lo  " 

"2.   Vertical  behind  cecum,     ....       i  case,    or     l^         " 

"3.   Toward  left  side,        I      "        "     l^         " 

"  (b)  Cecum  at  crest  of  ilium,  and  appen- 
dix lying  on  the  fjuadratus  lumboruni 
or    transversalis    muscle   and    directed 

slightly  to  the  right,       .         .  2  ca.se.s,  or    25         " 

"  (c)  Cecum  in  pelvis  and  appendix  upward 
and  toward  the  left  and  behind  ileum 
aho, 2      "        "     2^         "  " 

Etiology. — Appendicitis  in  all  it.s  pathologic  forms  is  es.sentially 
an  infective  microbic  di.sease.  Congenital  and  acquired  conditions 
determine  the  frequency  with  which  this  remnant  of  a  former  impor- 
tant organ  is  the  seat  of  infection  and  indamniation  as  compared  with 
other  more  active  jK^'tions  of  the  intestinal  canal.  The  embryologic 
proces.ses  in  this  location  are  of  a  complicated  nature,  and  may  have 
a  decided  influence  in  magnifying  the  su.sceptibility  to  infection.  The 
unrest  cau.sed  by  the  contractions  of  the  iliop.soas  mu.scle  (Hyron 
Robin.son)  may  play  a  subordinate  role  as  either  a  predi.spo.sing  or 
an  exciting  cau.se.  Its  dependent  po.sition,  its  comnnniication  by  an 
orifice,  more  or  le.ss  con.strictcd  and  often  imi)erfcctly  guarded  by 
Gerlach's  valve,  with  that  portion  of  the  intestine  in  which  in.spi.s.sa- 


7o8 


APPENDICITIS. 


tion   of  intestinal   contents  first   occurs,  while  at  the  same  time  it  is 
removed  from  the   direct   fecal   current,  are  decidedly  predisposing 


Fig.  460. — Blood  supply  of  the  appendix  as  found  in  the  majority  of  cases. 


iiColA 


Fig.  461. — Additional  blood  supply  to  the  appendix  from  cecal  branch.      Uncommon. 

conditions  to  infection,  which  satisfactorily  explain  the  frequency  with 
which  the  appendix  is  the  seat  of  inflammatory  affections.  The  par- 
tial exclusion  from  the  cecum  and   the   frequency  with  which  the 


ETIOLOGY. 


709 


valve  of  Gerlach  is  found  incompetent  likewise  explain  the  formation 
of  fecal  concretions,  which  are  so  often  found  in  connection  with  per- 
forative, ulcerative,  and  relapsing  catarrhal  appendicitis  that  they 
certainly  must  be  regarded  in  the  light  of  an  exciting  cause. 

A  glance  at  the  anatomy  of  the  appendix,  as  well  as  an  examina- 
tion of  the  most  constant  pathologic  conditions,  will  corroborate  the 
correctness  of  this  assertion.  The  appendix  is  richly  supplied  with 
lymphatic  vessels,  and  it  is  through  these  that  infection  most  fre- 
quently takes  place.  Orth  (Fig.  463)  has  fully  described  the  lymph- 
atic structures  in  the  appendix  of  the  rabbit,  and  Morris  has  recently 
alluded  to  the  lymphatic  channels  of  this  structure  as  a  route  of  in- 
fection in  man. 

It  is  not  difficult  to  understand  that  an  ordinaiy  catarrhal  inflam- 


Fig.  462. — Cecal  supply  from  ap])endicular  artery.      Rare. 


mation  would  render  the  mucous  membrane  permeable  to  the  pas- 
sage of  pathogenic  microbes,  rendering  it  pos.sible  for  them  to  pass 
from  the  lumen  of  the  appendix  into  the  lymphatics,  the  essential 
cause  of  the  inflammation  thus  coming  in  direct  contact  with  every 
anatomic  con.stituent  of  the  wall  of  the  apj)endi.\',  its  serous  invest- 
ment, and  even  the  free  peritoneal  cavity,  without  any  ulcerative 
perforation.  The  distribution  of  the  microbic  cau.se  through  the 
lymphatic  route  has  been  demon.strated  by  many  postmortem  ex- 
aminaticms  and  a[)[)endices  removed  by  oj)erative  treatment.  Minute 
miliary  abscesses  have  often  been  found  in  tlie  wall  of  the  appen- 
dix and  underneath  the  i)eritfmeal  coat,  and  usually  in  locations 
formerly  occupied  by  lymphatic  channels. 

It  is  evident  that  a  [)lastic  j)eritonitis  in  the  vicinity  of  the  appcn- 


710 


APPENDICITIS. 


dix  can  be  produced  by  pyogenic  microbes  without  visible  pus  within 
the  appendix  or  its  wall.  The  bacillus  coli  communis,  so  constantly 
found  in  the  intestinal  canal,  even  in  the  absence  of  disease,  is  the 
most  constant  microbic  cause  of  appendicitis.  This  microbe  appears 
to  be  harmless  as  long  as  the  mucous  membrane  of  the  appendix  is 
normal,  but  it  exercises  its  specific  pathogenic  properties  promptly 
whenever  the  essential  locus  viiiioris  rcsistenticB  is  produced  by  other 
conditions.  The  anatomic  location  of  the  appendix  is  such  that  re- 
tention of  its  secretions  is  likely  to  occur,  particularly  in  cases  in 
which  the  lumen  at  the  proximal  end  has  become  narrowed  by  con- 
genital stenosis  or  acquired  affections  of  the  cecal  wall.  From  a 
bacteriologic  aspect  the  appendix  must  be  regarded  as  an  open  test- 
tube,  and  the  retained  stagnant    secretions  as  a  culture-medium. 

Pus-microbes  un- 
doubtedly enter  large- 
ly into  the  etiology  of 
mixed  infections  here 
as  elsewhere.  Inten- 
sity of  the  inflam- 
mation is  determined 
more  by  the  quantity 
than  by  the  patho- 
genic quality  of  the 
microbes.  The  same 
cause  that  in  one  case 
produces  a  mild  form 
of  inflammation  may 
in  others  determine 
speedy  death  from 
gangrene  or  perfora- 
tion and  acute  sepsis. 
In  the  majority  of 
cases  the  appendix  re- 
ceives its  blood  supply 
from  a  single  branch 
of  the  ileocolic  artery,  which  runs  along  the  free  convex  border  of 
the  mesentery.  This  single  blood  supply,  as  well  as  the  pecuHar 
arrangement  of  the  meso-appendix,  accounts  for  the  very  serious 
disturbance  of  the  circulation  by  flexion  in  the  event  of  pressure 
produced  by  the  cecum  distended  by  gas  or  by  coprostasis.  Any- 
thing that  interferes  with  the  normal  circulation  in  the  appendix 
causes  local  conditions  favorable  to  infection.  The  extension  of  a 
catarrhal  inflammation  from  the  cecum  to  the  appendix  is  by  no 
means  a  rare  occurrence.  A  catarrhal  cecitis  acts  in  two  ways  in 
the  subsequent  development  of  a  similar  affection  of  the  appendix : 

1.  By  direct    extension  of   the    surface  inflammation  from  the 
cecum  to  the  appendix. 

2.  By  the  inflammatory  swelling  causing  a  stenosis  of  the  cecal 


Fig.  463. — Appendix  of  rabbit,  lymphatics  injected: 
f,  f,  f,  f.  Outer  follicles  with  lymph  sinus,  s,  s,  s  ; 
f'lf',/',  inner  follicles;  /,  /,  lymph-vessels  that  leave 
the  lymph-follicles  ;  m,  mucous  membrane  virith  dilated 
glands  ;  e,  their  epithelial  cells  ;  r,  r,  their  recesses  ;  r' , 
recess  ;  point  of  entrance  does  not  correspond  with  level 
of  section  (Orth). 


ETIOLOGY.  7  I  I 

end  of  the  lumen  of  the  appendix,  with  its  immediate  consequences 
— retention  of  the  secretions,  distention,  and  violent  appendicular  per- 
istalsis, conditions  favorable  to  infection. 

The  etiologic  influence  of  foreign  bodies  has  been  greatly  over- 
estimated. It  is  said  that  foreign  bodies  have  been  found  in  about 
4  per  cent,  of  all  operative  cases,  which  is  certainl}^  a  ver}''  high  esti- 
mate. I  found  foreign  bodies  in  only  two  cases  out  of  a  total  of 
more  than  300  operations  for  appendicitis.  In  the  case  of  a  young 
girl  the  subject  of  perforative  appendicitis,  a  piece  of  straw  was  found 
in  the  abscess  cavity.  In  the  second  case,  a  man  twenty-five  years 
of  age,  a  pin  was  found  in  the  perforation  and  projecting  into  the 
small  abscess  cavity  outside  of  the  appendix.  In  one  of  Fenger's 
cases  of  obliterating  appendicitis  two  grape -seeds,  one  fecal  concre- 
tion the  size  of  a  split-pea,  and  the  husk  of  an  oat  were  found  in  the 
appendix  below  the  obstruction.  Fecal  concretions  are  found  in 
from  1 5  to  20  per  cent,  of  all  cases  subjected  to  operative  treatment. 
Fecal  concretions  may  remain  in  the  appendix  indefiniteh'  without 
any  serious  consequences,  as  is  shown  by  their  presence  at  post- 
mortems in  otherwise  healthy  appendices.  They,  however,  undoubt- 
edly serve  frequently  as  a  provoking  cause. 

Fecal  concretions  are  concerned  in  two  distinct  ways  in  the  eti- 
ology of  appendicitis : 

1.  Their  presence  causes  a  mechanical  irritation  and  lesions  of 
the  mucous  membrane,  which  serve  as  infection  atria  for  the  entrance 
into  the  tissues  of  pathogenic  microbes. 

2.  In  case  the  appendix  becomes  swollen  from  mechanical  or  in- 
flammatory causes,  pressure  necrosis  directly  over  or  around  them 
ma}'  ensue,  as  is  so  often  seen  in  perforative  and  gangrenous  appen- 
dicitis. 

No  age  is  exempt  from  appendicitis,  although  the  disease  is 
much  more  frequent  in  the  adult  than  at  the  two  extremes  of  life. 
Women  are  less  subject  to  the  disease  than  men,  which  would  seem 
to  indicate  that  exposure  and  the  more  active  pursuits  of  life  exert 
an  influence  in  exciting  the  disea.se.  It  would  naturally  be  expected 
that  catarrhal  affections  of  the  intestinal  canal  would  frequently  be 
the  forerunner  and  direct  cau.sc  of  ai)pendicitis.  This  is  not  borne 
out  by  clinical  experience.  Catarrhal  affections  are  more  frequent 
in  infants  and  children  than  in  the  adult,  and  yet  children  are  seldom 
attacked  by  appendicitis. 

It  was  somewhat  astonishing  that  of  the  many  thousands  of 
soldiers  who  returned  from  Cuba  and  landed  at  Montauk,  not  one 
ca.se  of  appendicitis  came  to  my  attention  that  would  have  justified 
an  operation.  It  was  naturally  not  anticipated,  among  so  large  a 
body  of  men.  almost  all  of  them  at  s(jme  time  during  the  preceding 
five  months  the  victims  of  intestinal  affections,  that  the  appendix 
would  escape  infection  so  con.stantly.  'J  he  climate,  the  dirt,  the 
antecedent  intestinal  affections  contracted  in  home  camps  and  during 
the  campaign  in  Cuba,  slu)uld    have,  according  to  our  ideas  of  tlic 


712 


APPENDICITIS. 


nature  of  appendicitis,  combined  in  exciting  the  disease.  But  such 
was  not  the  case.  The  profession  is  very  well  aware  of  the  fact 
that  some  surgeons  who  can  see  nothing  else  but  appendicitis  in 
cases  in  which  patients  complain  of  pain  in  the  ileocecal  region  have 
performed  laparotomy,  and  the  cases  are  not  few  in  number  where, 
as  an  excuse  for  their  error  in  diagnosis,  they  have  completed  the 
operation  by  removing  a  normal  appendix.  Of  the  three  cases  of 
supposed  appendicitis  sent  to  the  surgical  wards  at  Montauk,  in  only 
one  the  diagnosis  proved  correct,  and  this  case  was  so  mild  a  one 
that  an  operation  was  not  deemed  justifiable.  One  proved  to  be 
malaria  and  the  third  typhoid  fever.  For  the  purpose  of  showing 
the  difficulties  that  surround  the  differential  diagnosis  between  appen- 
dicitis and  other  conditions  attended  by  pain  in  the  regions  of  the 
appendix  these  cases  will  be  related  briefly  : 

Case  i. — Charles  W.  Dyer,  age  nineteen,  Company  K,  Seventh  Infantry,  was  in  the 
service  only  six  weeks  when  he  was  taken  sick,  September  llth,  and  was  transferred  to 
the  surgical  ward  three  days  later.  The  attack  commenced  with  a  chill  and  some  fever  ; 
the  following  day  pain  in  the  right  iliac  region  set  in.  Bowels  were  constipated,  there 
was  no  vomiting,  but  loss  of  appetite.  He  had  had  a  similar  attack  a  year  ago.  On  his 
admission  to  the  surgical  ward  there  was  slight  tenderness  over  the  appendix  and  cecum, 
no  tympanites  and  no  palpable  swelling  or  muscular  rigidity,  and  temperature  was  only 
one  degree  above  normal.  Catarrhal  appendicitis  was  diagnosticated,  complicated  prob- 
ably by  a  similar  condition  of  the  cecum.  Rest  in  bed,  liquid  diet,  and  ounce-doses  of 
equal  parts  of  castor  oil  and  sweet  oil,  four  hours  apart,  until  bowels  moved  freely,  consti- 
tuted the  treatment  under  which  the  patient  recovered  in  a  few  days. 

Case  2. — James  Reid,  age  twenty-one,  Company  I,  Seventli  Infantry,  was  in  the 
service  three  months  when  he  was  admitted  to  the  surgical  ward,  September  1st,  with  the 
diagnosis  of  appendicitis.  The  clinical  history,  as  well  as  his  condition  at  the  time  of 
admission,  warranted  a  change  in  the  diagnosis  from  appendicitis  to  typhoid  fever.  The 
temperature  was  erratic,  showing  malarial  complication,  but  the  curve  from  day  to  day 
showed  the  typhoid  fever  part  to  our  satisfaction.  The  tongue  was  brown  and  dry,  with 
red  tip  and  margins.  Pulse  was  100,  and  temperature  at  that  time  varied  from  101°  to 
105°  F.  Abdomen  was  tympanitic  and  there  was  great  tenderness  in  the  right  iliac 
fossa.  Numerous  rose  spots  appeared  on  the  abdomen  the  next  day.  Under  appropriate 
treatment  the  fever  subsided  gradually  at  the  end  of  the  third  week  of  his  illness.  The 
great  tenderness  in  the  ileocecal  region  undoubtedly  led  originally  to  a  wrong  diag- 
nosis, but  it  simply  indicated  in  this  case  deep  typhoid  ulcers  in  the  lower  portion  of  the 
ileum. 

Case  3. — Martin  G.  Newman,  age  twenty-seven.  Company  C,  Seventh  Infantry, 
enlisted  three  months  before.  On  leaving  Santiago  he  began  to  feel  ill ;  with  headache, 
anorexia,  and  malaria  ;  became  worse,  lost  sleep,  and  complained  of  pain  in  the  stomach  : 
most  severe  on  left  side,  under  the  costal  arch ;  bowels  were  constipated,  tongue  was 
pale  and  flabby,  with  indented  margin.  Spleen  was  markedly  enlarged.  At  times  he  had 
pain  in  the  cecal  region,  which  disappeared  prompdy  after  the  administration  of  a  laxative. 
Under  quinin  in  large  doses  this  patient  improved  rapidly. 

From  the  foregoing  considerations  it  becomes  apparent  that 
much  additional  light  is  needed  to  ascertain  accurately  the  causes 
that  are  active  in  exciting  the  infection  that  constitutes  the  essential 
condition  of  every  attack  of  appendicitis. 

Pathology. — The  pathologic  conditions  of  appendicitis  vary 
according  to  the  extent  of  the  inflammation  and  the  tissues  involved. 
The  description  of  the  morbid  anatomy  must  be  based  on  a  proper 
classification.  From  a  practical  as  well  as  a  scientific  standpoint  it 
is  advisable  to  classify  appendicitis  into:  (1)  Catarrhal;  (2)  ulcer- 
ative; (3)  obhterative;  (4)  perforative;  (5)  gangrenous. 


Plate  3.. 


•'-^^^^ 


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^M- 


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1.  Catarrlial  appetulicilis.  Epithelial  lininp  inU-rniptcd  only  in  a  few  plate-,;  dila 
tation  of  tubular  glands  from  inflaininatory  obstruction  ;  inliltratioii  ol  diK  llcss  j^lands 
and  submucosa.     (Transverse  section.) 

2.  Ulcerative  appendicitis.      K|)ithelial  lining  coinijlelcly  destroyed  ;  niaikcd  uUda 
tion  and  deejj  inliltratioii.      (Transverse  .section.) 


CATARRHAL    APPENDICITIS.  713 

Catarrhal  Appendicitis. — This  is  the  mildest  form  of  appendi- 
citis. The  infection  and  resulting  inflammatory  conditions  are 
limited  to  the  mucous  membrane  and  the  loose  submucous  connec- 
tive tissue.  The  mucous  membrane  is  very  vascular  and  thickened, 
the  glandular  appendages  are  enlarged,  and  the  interglandular  con- 
nective tissue  is  infiltrated  (Plate  3).  The  tubular  glands  are  often 
found  considerably  dilated  b\-  retained  secretion.  Retention  of  secre- 
tion is  caused  by  the  swelling  of  the  mucous  membrane,  which 
brings  with  it  inflammatory  stenosis  of  the  open  end  of  the  tubules. 
The  lymph-follicles  are  markedly  enlarged  and  densely  packed  with 
lymphoid  cells  and  leukocytes.  The  swelling  of  the  mucous  mem- 
brane is  often  found  most  intense  on  the  cecal  side,  and  the  inflam- 
matory stenosis  is  then  sufficient  to  give  rise  to  obstruction  to  the 
free  passage  of  the  physiologically  increased  secretion  from  the 
lumen  of  the  appendi.N:  into  the  cecum.  It  is  in  cases  where  such 
an  obstruction  exists  that  the  retained  secretions  give  rise  to  violent 
peristaltic  action  of  the  muscular  coat  of  the  appendix,  the  cause  of 
the  so-called  appendicular  colic. 

Catarrhal  appendicitis  does  not  give  rise  to  any  severe  constitu- 
tional disturbances,  and  the  local  symptoms  are  limited  to  the  in- 
flamed organ.  The  most  prominent  local  symptoms  are  pain,  very 
often  of  an  intermittent  type,  and  tenderness,  limited  to  the  appendix. 
The  disease  is  usually  of  short  duration,  but  is  very  prone  to  recur- 
rence. Repeated  attacks  frequently  result  in  a  club-shaped  distal 
enlargement  of  the  appendix,  from  thickening  of  its  walls  and  in  con- 
sequence of  retention  of  secretions  from  flexion  or  inflammatory 
steno.sis  on  the  cecal  side.  The  elongation  of  the  organ  caused  by 
chronic  catarrhal  appendicitis  almost  constantly  leads  to  flexion  and 
ob.struction  (Plate  4).  The  mechanical  impediments  to  the  escape 
of  the  secretions  created  by  the  chronic  inflammatory  process  con- 
tributes largely  to  the  maintenance  of  the  infection  and  relapsing 
attacks.  In  all  cases  of  catarrhal  appendicitis  the  whole  mucous 
lining  eventually  becomes  involved,  but  there  are  usually  certain 
points  where  the  inflammatory  infiltration  is  most  intense  and  where 
the  more  remote  pathologic  conditions  are  most  marked.  If  the 
cecal  end  of  the  lumen  remain  freely  patent  and  the  disea.se  assumes  a 
chronic  form  or  relapses  frequently,  the  lumen  of  the  organ  becomes 
more  and  more  contracted  and  eventually  is  obliterated,  when  the 
mucous  membrane  and  its  glandular  appendages  have  become  de- 
stroyed by  the  inflannnatory  process  and  the  cicatricial  contraction 
following  it. 

Ulcerative  Appendicitis. — Catarrhal  inflammation  long  continued 
ultimately  results  in  the  formation  of  multiple  catarrhal  ulcers.  In 
the  ab.sence  of  localized  mechanical  cau.ses  inside  of  the  lumen  of  the 
appendix,  such  as  foreign  bodies  or  fecal  concretions,  the  ulcers  are 
usually  superficial  and  multiple,  but  in  the  course  of  time  their  depth 
is  increased  and  eventually  jjerforation  takes  [)lace.  .Such  an  occur- 
rence is  usually  complicated  by  the  exi.stence  of  a  mechanical  ob.struc- 


714 


APPENDICITIS. 


tion  on  the  proximal  side  of  the  ulcer.  So  long  as  the  infection 
remains,  such  ulcers  seldom  heal,  and  infection,  as  we  know,  is  most 
likely  to  remain  in  the  presence  of  a  mechanical  obstruction  on  the 
cecal  side.  In  the  most  favorable  cases  these  ulcers  finally  heal  by 
granulation  and  cicatrization,  but  always  at  the  expense  of  the  lumen 
of  the  appendix,  which  becomes  partially  or  completely  obliterated 
by  cicatricial  stenosis.  Such  strictures  may  be  found  either  single  or 
multiple  in  relapsing  appendicitis  (Plate  4).  The  destruction  of  tis- 
sue by  the  ulcerative  process  and  the  resulting  cicatricial  contraction 
from  partial  or  complete  healing  of  the  ulcers  are  often  followed  by 
great  shortening  and  distortion  of  the  appendix.  A  circumscribed 
plastic  peritonitis  often  complicates  catarrhal  and  ulcerative  ap- 
pendicitis by  the  extension  of  infection  to  the  serous  coat  through 
the  lymphatics,  when  the  peritoneal  adhesions  may  take  an  important 
part  in  the  process  of  deformation. 

3.  Appendicitis  Obliterans. — In  1894  I  called  attention  to  a 
pathologic    form    of  appendicitis    in  which   the   most    conspicuous 

feature  consists  in  a  gradual 
cicatricial  contraction  of  the 
lumen  of  the  appendix,  and 
which  I  termed  appendicitis 
obliterans.  Of  the  many  cases 
of  this  form  of  appendicitis 
that  have  come  under  my 
observation  since  that  time, 
reference  will  be  made  only  to  the  first  few  which  induced  me  to 
describe  this  distinct  pathologic  form  of  appendicitis.  My  views  in 
regard  to  its  pathology  and  clinical  significance  have  not  been 
changed  since  that  time.  The  distal  form  of  obliteration  is  well 
shown  in  figure  464,  a  specimen  from  Professor  Fenger's  collection. 
The  pathologic  processes  resemble  very  closely  a  similar  condition 
in  the  terminal  arteries,  designated  here  arteritis  obliterans.  The 
cases  here  mentioned  and  those  of  a  similar  nature,  presented,  before 
the  operation,  a  complexus  of  symptoms  that,  when  grouped  to- 
gether, will  enable  the  physician  to  at  least  suspect,  if  not  positively 
predict,  this  condition. 

Case  i. — H.  M.  Stewart,  aged  twenty-six;  business,  bookkeeper;  residence 
Lyons,  Kan.     Admitted  into  St.  Joseph's  Hospital  September  30,  1893. 

The  patient  stated  that  his  health  had  been  fairly  good  until  three  years  ago,  when 
he  suffered  from  an  attack  of  "cramps  in  the  stomach  "  and  pain  and  tenderness  in  the 
ileocecal  region.  This  attack  lasted  about  eight  hours.  Similar  attacks  followed  at 
intervals  of  two  or  three  months,  becoming  more  frequent,  until,  during  last  year,  they 
occurred  from  every  four  to  six  weeks.  The  acute  symptoms  would,  as  a  rule,  subside  in 
trom  SIX  to  fourteen  hours,  to  be  followed  by  a  dull  aching  pain  in  the  right  iliac  fossa, 
accompanied  by  tenderness  on  pressure  that  would  continue  for  from  ten  days  to  two 
weeks,  when  he  would  be  able  to  resume  his  occupation,  but  more  or  less  soreness  and 
tenderness  remained.  The  last  attack,  which  was  unusually  severe,  occurred  in  June. 
Operation  was  performed  October  2,  1893.  The  appendix  was  found  behind  the  cecum, 
directed  inward  and  upward.  It  was  adherent  to  the  cecum  and  a  loop  of  the  ileum  ; 
mesenteriolum  was  shortened  and  much  thicker  than  normal.  The  organ,  when  removed, 
measured  about  three  inches  in  length  and  presented  a  peculiar  club-shaped  appearance, 
the  constricted  portion  being  on  the  proximal  side,  while  the  free  end  was  bulbous.     The 


Fig.  464. — Appendicitis  obliterans  ;   cicatricial 
stenosis  on  distal  side. 


Plate  4, 


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APPENDICITIS    OBLITERANS.  715 

wall  of  the  free  bulbous  portion  was  much  thickened.  About  one-third  of  the  lumen  on 
the  proximal  side  was  completely  obliterated.  The  e.xcluded  part  contained  a  viscid 
fluid  of  a  brownish  color.  The  temperature  ranged  between  99°  and  100°  F.  for  four  days, 
when  it  reached  101.5°  F.  on  the  fifth  day,  after  which  it  became  normal.  The  patient 
left  the  hospital  at  the  end  of  the  fourth  week. 

C.A.SE  2. — J.  Barzhof,  aged  twenty-five.  German-American  ;  dentist ;  residence, 
Manitowoc,  Wis.  He  entered  St.  Joseph's  Hospital  at  the  request  of  his  attending  phy- 
sician, Dr.  Pritchard,  November  4,  1893.  Operation  on  the  following  day.  General 
health  fair.  In  the  summer  of  1888  he  was  taken  with  the  first  attack,  in  the  form  of 
severe  vomiting,  diarrhea,  and  intense  pain  in  the  abdomen,  radiating  upward  and  down- 
ward to  the  right  of  the  median  line.  The  first  seizure  lasted  about  four  days.  Similar 
attacks  occurred  about  four  times  even-  year.  In  the  spring  of  the  present  year  it  ap- 
peared that  the  attacks  were  provoked  by  change  in  diet.  Pain  often  more  severe  when 
stomach  was  empty.  Dietetic  treatment  had  no  effect  in  preventing  recurrence  of  the 
difficulty.  No  constipation.  Last  and  most  severe  attack  about  September  20th.  This 
was  preceded  by  a  .somewhat  hard  swelling,  extending  from  umbilicus  to  the  right 
Inguinal  region,  which  was  followed  by  a  severe  chill,  vomiting,  diarrhea,  and  the  char- 
acteristic sharp  lancinating  pain,  more  severe  in  the  ileocecal  region.  Highest  tempera- 
ture 102°  F.  The  pain  and  tenderness  in  the  ileocecal  region  never  disappeared  com- 
pletely after  this,  and  were  relieved  only  by  rest  in  the  recumbent  position.  On  opening 
the  abdominal  cavity  the  appendix  was  seen  at  once.  It  measured  at  least  five  inches 
in  length,  and  was  firmly  attached  to  the  caput  coli  and  extended  behind  the  colon.  The 
distal  bulbous  end  was  small.  A  similar  bulbous  expansion  was  found  near  its  attachment 
to  the  cecum.  Between  these  bulbous  expansions  the  organ  was  not  larger  than  a  small 
lead-pencil,  anemic,  and  very  dense.  Owing  to  the  length  of  the  mesenteriolum  it  had  to 
be  tied  in  four  sections.  The  glands  in  the  vicinity  were  found  much  enlarged, — some 
of  them  had  attained  the  size  of  an  almond, — but  none  of  them  presented  any  evidences 
of  caseation.  Examination  of  the  specimen  after  its  removal  showed  that  nearly  the  entire 
lumen  had  been  obliterated,  only  a  small  portion  on  the  distal  and  proximal  side  re- 
maining patent.  The  open  spaces  contained  a  catarrhal,  viscid  secretion  of  a  brownish 
color.  The  temperature  in  this  case  never  reached  100°  F. ,  and  the  patient  left  the 
hospital  at  the  expiration  of  four  weeks. 

C.-\SE  3.  —  Mrs.  E.  A.  West,  aged  twenty-eight,  American,  housewife;  residence, 
Decatur,  111.  Entered  St.  Joseph's  Hospital  at  the  suggestion  of  the  family  physician 
for  the  purpose  of  having  the  appendix  removed  for  a  recurrent  inflammatory  affection  in 
the  right  iliac  region  of  long  standing.  Her  mother  died  of  ])ulmonary  tuberculosis  when 
patient  was  only  six  months  old,  and  the  latter  has  always  been  in  delicate  health.  Mar- 
ried two  years;  no  children.  Six  years  ago  was  taken  suddenly  ill,  with  .symptoms  in- 
dicating peritonitis.  The  pain  was  diffu.se,  and  of  a  grinding  character.  The  acute 
symptoms  .subsided  in  five  or  six  hours,  but  she  was  confined  to  the  bed  for  four  days. 
The  tenderness  in  the  right  iliac  region  remained  for  a  number  of  days.  Later  in  the 
same  year  she  had  a  similar  attack,  and  during  each  of  the  succeeding  four  years  the  same 
experience  was  repeated  from  two  to  four  times.  Beginning  with  September,  1892, 
she  had  an  attack  each  month  until  February,  1893 — six  in  all.  The  attack  in 
February  was  .so  .severe  that  a  physician  was  calleil  for  the  fir.st  time.  As  in  all 
previous  attacks,  pain  passed  off  in  a  few  hours,  but  patient  was  confined  to  bed 
for  four  or  five  days,  and  tenderness  persisted  for  as  many  more  days.  She  was 
never  aware  of  the  exact  location  of  tenderness  until  she  was  examined  by  her  phy- 
sician. The  last  anfl  most  severe  attack  occurred  in  July  of  the  ])resent  year,  and 
lasted  twelve  days.  She  was  attended  by  Dr.  Bumstead,  who  recognized  the  difficulty 
and  advised  a  radical  operation.  During  the  last  attack  the  temperature  reached  103°  F. 
Vomiting  and  nausea  were  not  conspicuous  symptoms  during  any  of  the  attacks.  In  the 
beginning  of  the  acute  exaccrbatioTis  the  pain  was  gcncialiy  diffuse  ;  later,  localized  in 
the  ileocecal  region.  IIc>t  applications  always  afforded  j^roujpt  relief,  and  .she  believes 
that  they  were  the  means  of  cutting  short  several  of  the  attacks.  When  examined  after 
her  admission  into  the  hos])ital,  the  apj)endix  could  be  felt  as  a  firm  cord,  and  tenderness 
was  limited  to  this  structure.  f)p(ration  November  14th.  In  this  case  the  a||)endix  was 
directed  downward  and  inward  toward  the  pelvis  ;  adhesions  were  old  and  firm.  Mes- 
enteriolum was  very  short  and  adherent  to  a|>])en<lix.  It  was  lic(l  in  several  sections. 
Abfjut  one-fourlh  of  the  lumen  on  the  [)roximal  side  was  oblilcralcd,  and  the  corrcs|)ond- 
ing  |)ortion  of  the  a|)pendix  was  transformed  into  a  firm  fibrous  coril  (I'ig.  4'j5)-  i5<"yond 
this  (jblilerated  part  the  lumen  was  much  dilated,  and  subdivided  into  two  une(|ual  i)or- 
tions  by  a  thin  partition  composed  of  cicatricial  tissue.  Wall  of  a|>pendix  was  much 
thickened  afirl  dense.  B(jth  compartments  containe<l  inspissated  pus,  which  resembled 
lif|uefied  caseous  material.  Lymphatic  glands  in  the  vicinity  of  the  ajjpendix  were  much 
enlarged  and  exceedingly  vascular.      J'atient  recovered  without  an  unt<jward  .symptom. 


yi6 


APPENDICITIS. 


A  small  stitch  abscess  at  the  end  of  a  week  gave  rise  to  a  slight  elevation  of  temperature, 
and  slightly  retarded  the  healing  of  the  wound. 

Case  4. — J.  H.  Croskey,  aged  thirty-three,  American  ;  farmer  by  occupation ;  resi- 
dence, Farmer  City,  111.  Entered  St.  Joseph's  Hospital  December  5,  1893.  Family 
history  good.  Patient  was  never  sick  until  Nqvember,  1891,  when,  after  a  hard  day's 
work,  he  experienced  a  dull  pain  in  right  side  and  lower  part  of  abdomen.  He  was  able 
to  sit  up,  but  could  do  no  work  for  three  days,  when  all  symptoms  passed  away.  There 
was  no  nausea  or  vomiting ;  a  little  tympanites  and  constipation  were  present.  He 
attributed  the  difficulty  to  a  strain  produced  by  lifting.  The  second  attack  in  April,  the 
following  year,  commenced  with  a  sudden,  sharp,  intense  pain,  confined  to  the  right  side, 
in  the  region  of  the  appendix.  The  acute  symptoms  continued  for  one  month,  during 
which  time  he  was  confined  most  of  the  time  to  bed,  but  at  any  time,  if  assisted  to  his 
feet,  he  could  walk  with  the  aid  of  a  cane.  During  the  second  month  he  improved  suf- 
ficiently to  resume  his  work.  A  sense  of  soreness  and  tenderness  in  the  ileocecal  region  re- 
mained. Vomiting  occurred  on  the  evening  of  the  second  day.  Tympanites  was  absent. 
Diagnosis  of  appendicitis  was  made  on  the  fourth  day  by  the  attending  physician.  Third 
attack  occurred  in  February,  1893,  and  resembled  the  second  in  every  respect.  There 
remained  not  so  much  tenderness  on  pressure  as  a  soreness  or  pain  from  a  slight  jar,  as 
would  happen  when  riding  in  a  buggy  when  the  wheel  struck  a  stone.  Could  not  stand 
perfectly  erect,  but  would  incline  the  body  slightly  forward  and  to  the  right,  with  feet  about 
twelve  inches  apart.  Examination  before  operation  revealed  tenderness  in  the  region  of 
the  appendix  on  deep  pressure.  Operation  December  8,  1893.  The  appendix  was  readily 
found,  as  it  was  directed  forward  and  to  the  right,  occupying  a  groove  in  the  caput  coli. 


Fig.  465. — Appendicitis  obliterans  :  I,  Proximal  end  completely  obliterated  ;  2, 
narrow  stricture  dividing  completely  the  remaining  lumen  into  two  unequal  portions ; 
great  thickening  of  wall  near  distal  end. 


Separation  from  the  cecum  was  very  difficult,  as  the  peritoneal  coat  of  the  latter  appeared 
to  be  absent  and  the  muscular  coat  very  much  attenuated.  The  dissection  was  made 
slowly  and  carefully,  and  mainly  with  the  aid  of  blunt  instruments.  The  mesenteriolum 
was  incorporated  so  firmly  in  the  adhesions  that  ligation  was  rendered  superfluous.  A 
number  of  bleeding  points  were  ligated.  The  appendix,  when  removed,  measured  three 
inches  in  length,  and  on  slitting  it  open  it  was  found  that  about  one-third  of  its  lumen  on 
the  distal  side  was  completely  obliterated.  The  distal  end  tapered  into  a  sharp  point. 
The  wall  of  the  remaining  portion  was  only  slightly  thickened.  Mucous  membrane  was 
intensely  congested.  At  a  point  about  half  an  inch  distant  from  obliterated  part  both 
the  wall  of  the  appendix  and  its  lumen  showed  changes  that  indicated  the  first  stages  of 
the  formation  of  a  circular  stricture.      Mucous  membrane  was  much  thickened. 

In  this  case  the  second  attack  of  appendicitis  produced  an  intense 
localized  plastic  peritonitis  that  gave  rise  to  the  extensive  and  firm 
adhesions  of  the  appendix  to  the  cecum,  rendering  the  operation  one 
of  great  difficulty. 

Case  5. — James  McChane  ;  occupation,  farmer  ;  aged  thirty-five  years  ;  married  ; 
mother  died  of  phthisis.  Personal  history:  Never  a  very  robust  man.  Had  "ague" 
eight  years  ago,  lasting  three  months.      Regular  in  habits  ;   no  venereal  history. 

In  August,  1893,  the  patient,  while  threshing  wheat,  was  attacked  with  a  severe 
paroxysm  of  pain  in  the  right  lumbar  region.  He  had  to  stop  work,  but  did  not  go  to 
bed.  He  has  not  been  able  to  do  a  day's  work  since,  although  he  has  not  been  con- 
fined to  his  bed.  The  pain  was  always  present, — a  dull  aching  pain,— and  the  least 
exertion  aggravated  the  difficulty  and  tenderness.  The  pains  were  always  referred  to  the 
same  pomt— a  few  inches  to  the  right  and  below  the  umbilicus. 


APPENDICITIS    OBLITERANS.  717 

The  bowels  were  constipated,  and  the  patient  resorted  to  the  use  of  enemata  to  relieve 
them.  The  appetite  was  very  poor,  and  he  lost  flesh  steadily.  When  admitted,  the 
patient's  temperature  was  normal  in  the  morning,  with  a  slight  evening  rise. 

On  physical  examination,  a  point  of  tenderness  was  found  corresponding  to  Mc- 
Bumey's  point,  with  some  induration  afid  fixation  of  the  head  of  cecum. 

From  the  clinical  history  and  existing  symptoms  it  was  not  difficult  to  make  an 
almost  positive  diagnosis  of  appendicitis  obliterans  before  the  operation.  The  operation 
was  perfomied  in  the  clinic  of  Rush  Medical  College.  The  distal  end  was  patulous,  and 
the  proximal  end  completely  obliterated. 

The  cases  just  reported  present  man}'  clinical  features  in  com- 
mon. The  age  of  the  patients  varied  from  twenty-five  to  thirty- 
eight.  Four  were  males,  and  one  was  a  female.  In  all  of  them  the 
acute  exacerbations  were  characterized  by  s\mptoms  of  peritonitis 
of  varying  intensitx'.  Swelling  docs  not  appear  to  have  been  a  con- 
stant feature,  either  during  or  after  the  acute  attack.  In  most 
instances  the  pain  was  at  first  diffuse  or  referred  to  the  epigastric 
region  ;  later,  localized  in  the  ileocecal  region.  In  most  of  the 
cases  tenderness  in  the  region  of  the  appendix  remained  a  long  time 
after  tiie  subsidence  of  the  acute  .S)'mptoms,  or  persisted  as  a  perma- 
nent condition.  The  point  of  tenderness  varied  according  to  the 
location  of  the  appendix.  The  febrile  disturbance  during  the  acute 
attack  appears  to  haxe  been  moderate  and  of  short  duration. 
Nausea  and  vomiting  were  not  con.stant  .symptoms.  Tympanites 
depended  on  the  extent  of  the  peritoneal  involvement.  The  most 
constant  and  characteristic  feature  was  recurrence  of  the  acute 
exacerbations,  which  set  in  from  once  a  year  to  every  few  weeks. 
As  a  rule,  the  attacks  become  gradually  more  frequent.  In  two  out 
of  the  five  cases,  some  of  the  important  s\'mptoms  remained  in  a 
masked  form  during  the  intermissions.  This  was  noted  particular!}' 
in  the  cases  in  which  the  appendix  was  obliterated  on  the  proximal 
side.  Absence  of  complete  intermis.sion  between  attacks  points  to 
the  existence  of  stenosis  or  obliterations  on  the  proximal  side. 

From  what  has  been  saitl  it  will  be  seen  that  the  most  conspicu- 
ous .symptoms  of  this  form  of  appendicitis  are  :  (i)  Short  duration 
and  moderate  intensity  of  the  acute  exacerbations  ;  (2)  slight  or  no 
swelling  in  the  region  of  the  appendix  ;  (3)  recurrence  of  acute 
attacks,  varying  in  frequency  from  a  year  to  .several  weeks  ;  (4) 
persistence,  during  the  intermission,  of  some  .soreness  and  tenderness 
in  the  part  affected. 

Ribbert  wished  to  ascertain  the  frequency  with  which  the  appen- 
dix vermiformis  undergoes  obliteration,  and  for  this  purj)o.se  noted 
the  condition  of  this  organ  in  400  postmortem  examinations.  He 
found  partial  or  complete  obliteration  in  25  per  cent,  of  these  cases. 
Jfe  believes  that  this  change  is  due  to  involutionary  changes  in  the 
majority  of  cases.  One  reason  for  entertaining  this  idea  is  that  this 
condition  of  the  appendix  is  met  more  frequently  in  persons  advanced 
in  years.     The  influence  of  age  is  shown  in  the  following  table  : 

1  decennium 4  per  cent.        5  flcccnnium 36  per  cent. 

2  "  17       "  (>  "  5.^       " 

4         "  27       "  7  "  5S       " 


7i8 


APPENDICITIS. 


In  favor  of  the  inflammatory  origin  of  appendicitis  obliterans  it 
can  be  said  that  appendicitis  is  a  comparatively  rare  affection  in  chil- 
dren, and  that  the  longer  the  person  lives,  the  greater  the  liability 
to  suffer  from  an  attack.  There  can  be  but  little  doubt  that  obliter- 
ation of  the  appendix  occasionally  occurs  as  a  congenital  condition. 
Atresia  of  the  lumen  of  this  organ  is  probably  more  liable  to  occur 
during  intra-uterine  life  than  is  the  same  condition  in  other  parts  of 
the  gastro-intestinal  canal. 

Pathology  and  Morbid  Anatomy. — Ran  vers  found  the  appendix 
completely  obliterated  in  thirteen  postmortem  examinations.  All 
the  specimens  showed  evidences  of  circumscribed  plastic  peritonitis. 
He  believed  that  in  some  of  these  cases  perforation  had  taken  place, 
and  that  the  disease  ultimately  cured  itself  In  one  specimen  he 
found  a  small  fecal  concretion  surrounded  by  a  capsule  of  cicatricial 
tissue.  Tlie  most  striking  morbid  changes  in  obliterating  appendi- 
citis are  found  in  the  different  tissues  of  the  organ,  and  these  are 
directly  concerned  in  the  gradual  and  progressive  obliteration  of  its 
lumen.  A  stricture  of  the  appendix,  like  that  of  any  other  hollow 
organ,  may  be  brought  about  by  :  (i)  Destruction  of  the  mucous 
membrane  by  ulceration  ;  (2)  infiltration,  thickening,  and  contraction 
of  the  muscular  coat ;  (3)  prolonged  cicatricial  contraction  of  exu- 
dates upon  its  serous  covering  ;  (4)  in  consequence  of  a  combina- 
tion of  two  or  more  of  these  causes. 

The  obliteration  is  always  preceded  by  destruction  of  the  epithe- 
lial lining  by  the  inflammatory  processes,  aided  later  by  cicatricial 
contraction  following  the  healing  of  the  ulcerating  surface  by  gran- 
ulation. Epithelial  remains  in  the  scar  tissue  are  finally  destroyed 
by  the  progressive  cicatricial  contraction  and  avascularization. 

Perforative  Appendicitis. — The  tissues  around  the  appendix, 
particularly  the  peritoneum,  may  or  may  not  be  involved  in  catarrhal, 
ulcerative,  or  obliterating  appendicitis.  In  perforative  appendicitis 
the  complicating  para-appendicular  affections  constitute  the  most  con- 
spicuous part  of  the  clinical  picture.  An  acute  necrosis  of  the  wall 
of  the  appendix  over  a  limited  space  may  result  in  perforation  within 
forty-eight  hours,  followed  by  circumscribed  or  diffuse  phlegmon  or 
peritonitis,  according  to  the  location  and  size  of  the  perforation  and 
the  amount  and  virulence  of  the  infective  cause.  Postmortem  exami- 
nations have  shown  conclusively  that,  with  few  exceptions,  perityph- 
litis and  paratyphlitis  are  preceded  by  a  primary  appendicitis,  so  that 
in  all  acute  inflammatory  processes  in  the  ileocecal  region  an  appen- 
dicitis must  be  suspected  as  the  primary  cause.  Every  perforative 
appendicitis  is  followed  by  peritonitis  of  greater  or  less  extent.  A 
retrocecal  phlegmonous  inflammation  will  occur  if  the  perforation 
takes  place  in  this  direction,  which  can  occur  only  by  the  accident 
being  preceded  by  a  plastic  peritonitis  shutting  out  the  peritoneal 
cavity  from  the  focus  of  infection.  In  such  an  event  the  subsequent 
course  of  the  disease  is  attended  by  signs  and  symptoms  of  acute 
abscess  formation  behind  the  cecum.      Such  an  abscess  may  find  its 


GANGRENOUS    APPENDICITIS.  yiq 

way  as  far  as  the  under  surface  of  the  liver,  simulating  a  paranephric 
abscess,  or  it  may  reach  the  surface  near  the  spine  of  the  ilium  or 
above  Poupart's  ligament.  In  other  cases  the  perforation  leads  to 
a  plastic  peritonitis  that  walls  off  the  peritoneal  cavity  and  the 
abscess,  intraperitoneal  from  the  beginning,  may  rupture  into  the 
cecum,  a  loop  of  the  small  intestine,  the  rectum,  bladder,  or  va-ina 
I  he  most  serious  consequences  occur  in  cases  of  perforation  with 
the  escape  of  the  inflammatory  product  into  the  free  peritoneal  cavity 
in  which  event  a  diffuse  septic  peritonitis  and  death  are  the  usual 
consequences  unless  the  latter  can  be  prevented  by  prompt  opera- 
tive interference.  In  case  the  perforation  is  small  and  a  plastic  peri- 
tonitis limits  the  escape  of  septic  material,  suppuration  does  not 
lollow  as  an  inevitable  result.  In  such  instances  a  hard  inflamma- 
tory- swelling  makes  its  appearance,  which  in  the  course  of  time  dis- 
appears by  absorption,  leaving  the  appendix  embedded  permanently 
in  adhesions. 

In  relapsing  appendicitis  the  inflammatory  swelling  appears 
toward  the  end  of  the  acute  exacerbation,  uhen  it  diminishes  in  size 
or  disappears  entirely,  to  reappear  during  the  next  attack.  Perfor- 
ation may  follow  recurring  attacks  of  appendicitis  as  the  result  of  a 
chronic  ulcerative  process,  usually  in  combination  with  a  mechanical 
obstruction,  but  in  the  great  majority  of  cases  it  presents  itself 
clinically  as  an  acute  process,  perforation  taking  place  in  from  a  few 
hours  to  several  days  from  the  beginning  of  the  first  symptoms. 
The  pathologic  anatomy  in  such  cases  presents,  as  the  most  con- 
spicuous feature,  a  circumscribed  necrosis  of  the  wall  of  the  appen- 
dix. If  a  fecal  concretion  is  present,  the  perforation  usually  corre- 
sponds to  its  location,  which  would  indicate  that  the  pressure  caused 
by  the  fecal  concretion  in  the  inflamed  swollen  appendix  had  some- 
thing to  do  with  causing  the  necrosis.  In  the  absence  of  such  a 
local  cause  we  must  assume  that  the  inflammation  eventuates  in 
necrosis  by  obstructing  the  vessels  in  the  necrosed  territory. 

Gangrenous  Appendicitis.— In  this  form  of  appendicitis  a  part 
of,  or  the  whole  appendix  is  destroyed.  (Gangrenous  appendicitis  is 
alwavs  an  acute  process.  The  inflammation  and  the  conditions  in- 
duced by  it  may  be  so  .severe  that  gangrene  takes  j^lace  in  the  course 
of  twenty-four  hours.  I  have  seen  a  number  of  cases  of  appendicitis 
in  which  laparotomy  was  performed  in  less  than  thirty-six  hours 
after  the  appearance  of  the  first  .symptoms,  and  found  in  such  in- 
-stanccs  tlie  entire  organ  gangrenous.  The  mo.st  caieful  examination 
of  the  specimens  removed  showed  no  evidences  of  perforation.  In 
two  ca.scs  of  gangrenous  appendicitis  that  recovered  after  the  abscess 
ruptured  into  the  bowel,  pain  and  tenderness  remained  in  the  right 
iliac  fos.sa,  where  a  limited  induration  could  easily  be  detected. 
Operation  several  years  after  the  acute  attack  revealed  about  half  an 
inch  of  the  di.stal  end  of  the  appendix  buried  in  a  ma.ss  of  ad- 
hesions, and  entirely  detached  from  the  cecum.  In  both  specimens 
the  lumen  of  the  isolated  ];art  of  the  organ  contained  a  few  drops  of 


720 


APPENDICITIS. 


a  viscid  fluid  of  a  brownish  color.  The  gangrenous  portion  in  both 
of  these  instances  was  ehminated  with  the  contents  of  the  abscess, 
and  the  survival  of  the  tip  of  the  organ  must  necessarily  be  attributed 
to  a  separate  blood  supply,  either  through  blood-vessels  in  ante- 
cedent adhesions  or  from  other  source  aside  from  the  principal  artery 
of  the  appendix.  Total  gangrene  of  the  appendix  is  always  associ- 
ated with  thrombosis  of  the  principal  blood-vessel,  and  the  complete 
arrest  of  the  circulation  is  the  direct  cause  of  the  gangrene.  Mal- 
position of  the  appendix,  abnormality  of  its  principal  blood-vessels, 
and  acquired  conditions  that  interfere  mechanically  with  the  necessary 
blood  supply  are  undoubtedly  the  most  frequent  and  potent  predis- 
posing causes  of  the  gangrenous  inflammation.  The  direct  imme- 
diate cause,  however,  is  to  be  found  in  the  infective  process  which 
determines  the  thrombosis.  The  veins. undoubtedly  are  always  first 
occluded  by  a  progressive  thrombophlebitis,  which  extends  from  the 
inflamed  wall  to  the  mesenteriolum,  resulting  finally  in  occlusion  of 

the  principal  vein  that  returns  the  blood 
from  the  appendix  and  the  meso-appen- 
dix.  The  complete  arrest  of  the  venous 
circulation  is  soon  followed  by  throm- 
bosis on  the  arterial  side,  complete  arrest 
of  the  circulation,  and  the  inevitable  re- 
sult— gangrene. 

Fis".  466. — Distal  portion  of  tt    1  j.  •      1     i.        i.  i. 

append^  isolated  from  the  cecum  .  Unless  prompt  surgical  treatment 
and  embedded  in  scar  tissue  after  is  resorted  to,  gangrenous  appendicitis 
an  attack  of  gangrenous  appendi-      \q^^.    jn   a  great  majority  of  cases,  to 

citis.        Ihe    lumen    contained    a  .  ...  i     1        1  t^i 

gelatinous  substance,  and  a  cul-  septic  peritonitis  and  death.  1  here  are, 
tare  made  from  it  yielded  a  however,  exceptions  to  sucli  a  course. 
growth  of  staphylococcus   pyo-      y^^^^  favorable  circumstances  a  plastic 

genes  albus.  ......  -  ^ 

peritonitis  limits  the  infection,  and  ab- 
scess forms  in  which  the  detached  gangrenous  appendix  is  "later 
found  as  part  of  its  contents.  But  even  under  the  most  favorable 
circumstances  the  disease  pursues  a  very  rapid  course  and  demands 
operative  treatment  as  soon  as  a  diagnosis  can  be  made. 

Symptoms  and  Diagnosis. — The  symptoms  of  appendicitis  must 
necessarily  vary  according  to  the  pathologic  forms  of  the  disease 
and  the  absence  or  presence  of  peritoneal  complications.  In  per- 
forative and  gangrenous  appendicitis  the  primary  affection  is  soon 
overshadowed  completely  by  the  resulting  peritonitis.  The  local 
symptoms  are  most  characteristic  in  the  catarrhal  and  obliterating 
varieties.  In  such  cases  the  pain  is  usually  referred  at  first  to  the 
region  of  the  umbilicus,  for  the  reason,  as  has  been  suggested,  that 
during  the  early  stages  of  the  embryologic  development  of  the  in- 
testinal canal  the  appendix  is  found  in  that  locality.  In  this  respect 
the  appendix  furnishes  an  analogy  to  the  testicle,  in  which,  when  the 
seat  of  a  painful  affection,  the  pain  is  referred,  in  part,  at  least,  to  a 
point  occupied  by  the  organ  during  embryonic  life.  Others  believe 
that  this  distant  pain  is  caused  by  a  reflex  implication  of  the  great 


SYMPTOMS    AND    DIAGNOSIS.  72 1 

sympathetic  ganglia  situated  in  that  region.  The  characteristic 
pain  of  appendicitis  corresponds  with  the  location  of  the  organ,  the 
attached  portion  of  which  is  found  almost  invariably,  as  was  pointed 
out  by  McBurne}',  on  a  line  drawn  from  the  anterior  superior 
spinous  process  of  the  ilium  to  the  umbilicus,  and  about  half-way 
between  these  two  points.  This  is  McBurney's  point,  so  constantly 
referred  to  in  the  discussions  on  inflammatory  affections  of  the 
appendix  and  their  operative  treatment.  This  point  corresponds 
with  the  cecal  end  of  the  appendix,  while  the  organ  itself  may  be 
found  displaced  in  almost  any  direction  and  any  part  of  the  abdomi- 
nal cavity.  The  appendix  has  been  found  in  the  pelvis,  in  the  region 
of  the  sigmoid  flexure  or  of  the  umbilicus,  and  even  under  the  surface 
of  the  liver,  but  its  origin  from  the  cecum  is  almost  constant  and 
corresponds  with  McBurney's  point. 

Tenderness  is  a  more  important  diagnostic  evidence  than  pain. 
In  the  absence  of  peritonitis  the  tenderness  is  limited  to  the  inflamed 
organ  and  serves  as  a  guide  to  its  location.  In  catarrhal  and 
obstructive  appendicitis  the  pain  is  often  colicky,  and  has  been 
referred  to  exaggerated  peristalsis  (Morris),  constituting  the  so-called 
appendicular  colic.  The  inflammatory  swelling  incident  to  appendi- 
citis varies  in  size  and  character  according  to  the  amount  and  nature 
of  the  inflammatory  product. 

The  normal  appendix  can  seldom  be  outlined  by  palpation, 
which  is  contrary  to  what  has  been  asserted  by  Edebohls  and 
others.  It  is  usually  fowid  difficult  to  locate  the  slightly  enlarged 
appendix  by  palpation,  and  the  absence  of  a  palpable  szvelling  does  not 
exclude  the  presence  of  a  catarrhal  appendicitis.  If  the  appendicitis 
has  given  rise  to  a  circumscribed  peritonitis,  a  hard  and  tender 
swelling,  variable  in  size,  indicates  the  exact  location  of  the  diseased 
organ.  If  the  appendix  is  located  behind  the  cecum,  as  is  so  often 
the  case,  a  swelling  of  considerable  size  may  elude  palpation.  Owing 
to  the  tenderness  and  rigidity  of  the  abdominal  wall,  it  is  extremely 
difficult  to  detect  fluctuation  if  suppuration  has  taken  place  unless 
the  abscess  is  large  or  has  reached  a  stage  where  it  has  resulted  in 
a  marked  bulging  of  the  abdominal  wall.  So  far  as  palpation  is 
concerned,  a  large  retrocecal  intraperitoneal  abscess  often  very  closely 
simulates  an  extraperitoneal  abscess.  Muscular  rigidity  is  a  promi- 
nent clinical  feature  of  appendicitis,  and,  as  a  rule,  it  is  proportionate 
to  the  severity  and  extent  of  the  complicating  peritonitis.  Retraction 
of  the  thigh  is  an  indicatio?t  of  the  extension  of  the  ijiflammation  in 
the  direction  of  the  sheath  of  the  iliopsoas  muscle,  and  is  met  most  con- 
stantly in  retrocecal  suppuration. 

The  treacherous  nature  of  appendicitis  becomes  more  suspicious 
in  the  study,  at  the  bedside,  of  general  than  of  local  symptoms.  The 
gravest  cases  are  often  initiated  by  a  comple.xus  of  symptoms  that 
furnish  no  indication  whatever  of  the  lurking  danger  hidden  behind 
it,  and  mild  cases  often  present  themselves  attended  by  symptoms 
indicative  of  a  far  graver  conditifjii  than  really  exists.  The  pul.se 
46 


722 


APPENDICITIS. 


and  temperature  are  especially  misleading,  more  particularly  so  in 
children.  I  have  operated  repeatedly  in  cases  in  which  the  consti- 
tutional symptoms  were  of  a  severe  type,  and  found,  to  my  utter 
astonishment,  a  plain  case  of  appendicitis  without  perforation  or 
peritonitis  to  any  considerable  extent.  I  have  been  lured  into  a 
sense  of  security  by  a  temperature  not  far  from  normal  and  a  good 
pulse,  and  found,  a  (ew  days  later,  when  forced  to  operate  by  a  sud- 
den aggravation  of  the  symptoms,  a  gangrenous  or  perforated  ap- 
pendix, extensive  pus-formation,  or  a  diffuse  septic  peritonitis.  It  is 
the  difficulty  of  interpreting  correctly  the  early  symptoms  of  appen- 
dicitis that  makes  it  often  so  trying  a  task  to  decide  whether  to  oper- 
ate or  to  pursue  a  conservative  course.  While  the  initial  symptoms 
are  well  calculated  to  leave  doubts  in  the  mind  of  the  surgeon  as  to  the 
propriety  of  resorting  to  operative  interference,  there  can  be  no  ques- 
tion as  to  the  advisability  of  doing  so  when  the  symptoms  increase 
progressively  in  intensity.  If  the  temperature  continues  to  rise  and  the 
pulse  increases  in  frequency  after  the  first  tzventyfour  hours,  it  is  safe  to 
assume  that  the  appendicitis  has  resulted  in  complications  that  tvar- 
rant  operative  treatment.  The  same  can  be  said  of  a  gradually  in- 
creasing tympanites.  Vomiting  is  a  frequent,  but  by  no  means  a 
constant,  symptom.  The  disease  is  often  preceded  and  accompanied 
by  constipation,  but  the  reverse  may  be  the  case. 

In  the  differential  diagnosis  between  appendicitis  and  the  affec- 
tions resembling  it  the  greatest  care  is  required,  as  healthy  appen- 
dices have  been  repeatedly  removed  for  symptoms  caused  by  other 
diseases,  and  many  cases  of  appendicitis  have  been  overlooked  and 
treated  for  other  affections  when,  perhaps,  operative  treatment  was 
urgently  indicated.  The  most  important  symptoms  upon  which  to 
base  the  diagnosis  of  appendicitis  are  the  following  :  Pain  and  tender- 
ness in  the  region  of  the  appendix,  fever,  muscular  rigidity,  tym- 
panites, vomiting,  and  very  often  either  constipation  or  diarrhea. 
Another  circumstance  important  to  remember  is  that  the  attack  is 
usually  ushered  in  suddenly  without  any  premonitory  symptoms. 
In  the  grave  forms  of  the  disease  progressive  aggravation  of  symp- 
toms is  to  expected,  although  sometimes  the  acute  symptoms 
diminish  in  severity  after  a  few  days,  and  a  lull  precedes  the  subse- 
quent more  stormy  and  progressive  symptoms. 

Typhlitis  in  many  respects  very  closely  resembles  appendicitis, 
but  the  rarity  of  this  disease  as  compared  with  appendicitis  must  be 
remembered  in  making  the  differential  diagnosis  between  these  two 
acute  inflammatory  affections  in  the  ileocecal  region.  Typhlitis  is 
usually  attended  by  coprostasis,  and  the  existence  of  a  doughy 
swelling  in  the  cecal  region  during  the  beginning  of  the  attack 
speaks  strongly  in  favor  of  typhlitis.  If  any  doubt  exists,  the  ad- 
ministration of  a  laxative  and  a  high  enema  will  often  promptly 
confirm  or  correct  the  diagnosis. 

Tuberculosis  of  the  cecum  is  a  chronic  affection  and  lacks  most 
of  the  clinical  features  that  characterize  appendicitis. 


TREATMENT. 


723 


It  is  more  difficult  to  differentiate  between  some  forms  of 
mechanical  intestinal  obstruction  and  appendicitis.  As  a  rule,  in 
intestinal  obstruction  the  constipation  is  absolute,  vomiting  per- 
sistent, and  the  intestinal  peristalsis  violent.  Appendicitis  is  always 
attended  by  more  or  less  rise  in  the  temperature,  tenderness  in  the 
region  of  the  appendix — symptoms  that  are  absent  in  intestinal 
obstruction. 

Intestinal  catarrh  caused  by  the  ingestion  of  indigestible 
food  often  manifests  itself  by  s}-mptoms  that  might  suggest  an 
appendicitis,  and  the  diagnosis  is  often  uncertain,  as  it  is  well  known 
that  acute  indigestion  frequently  precedes  appendicitis.  The  diarrhcea 
crapidosa  and  the  gaseous  distention  of  the  intestines  almost  from 
the  beginning  of  the  attack  are  strong  evidences  in  favor  of  acute 
indigestion  and  against  appendicitis.  Castor  oil  in  laxative  doses 
will  decide  the  diagnosis  in  a  few  hours. 

Renal  colic  has  been  mistaken  for  appendicitis,  and  vice  versa. 
The  passage  of  a  renal  calculus  is  attended  by  the  most  excruciating 
pain  along  the  ureter,  and  frequently  b\'  retraction  of  the  testicle  on 
the  corresponding  side.  E.xamination  of  the  urine  will  prove  of 
great  diagnostic  v^alue  in  making  the  differential  diagnosis  between 
these  two  affections.  Renal  colic  does  not  give  rise  to  fever,  and 
is  not  attended  by  any  symptoms  indicative  of  intestinal  or  per- 
itoneal irritation.  The  passage  of  a  biliar}'  calculus  is  inaugurated 
by  intense  paroxysmal  pain  in  the  upper  right  segment  of  the  abdo- 
men, w'hich  radiates  to  the  back  or  shoulder  of  the  same  side,  and 
chills  and  vomiting  are  the  rule.  If  the  obstruction  lasts  for  any 
length  of  time,  jaundice  appears,  which,  if  any  doubt  remained, 
sets  this  aside. 

In  the  female  ovaritis  and  salpingitis  add  to  the  difficult}'  in 
establishing  the  diagnosis  of  appendicitis.  Combined  vaginal  and 
abdominal  palpation  is  to  be  relied  upon  in  making  a  differential 
diagnosis  between  these  two  inflammatory  affections  of  the  female 
internal  organs  of  generation  and  appendicitis. 

Treatment. — The  rational  treatment  of  appendicitis  must  de- 
pend entirely  on  the  anatomicopathologic  form  of  the  disease.  The 
views  of  the  profession  on  this  subject  at  the  present  time  might  be 
divided  into  three  categories  :  (i)  Exclusively  surgical  ;  (2)  exclu- 
sively medical  ;  (3)  medical  treatment,  as  a  rule,  surgical  treatment 
in  cases  in  which  the  indications  for  an  operation  are  clear.  Ex- 
treme doctrines  are  seldom  tenable,  and  one-sided  exclusive  practice 
is  never  safe.  There  arc  few  rules  without  exceptions,  and  this  is 
particularly  applicable  to  the  practice  of  medicine  and  surgcr)-.  It 
would  be  difficult  to  find  a  physician  to-day,  no  matter  how  well  in- 
formed and  eminent  he  might  be,  who  would  feel  that  he  had  dis- 
charged his  duty  to  his  patients  suffering  from  appendicitis  by 
making  a  diagnosis  and  then  handing  them  over  to  the  surgeon  for 
operative  treatment.  There  are  only  a  few  surgeons  who  make  the 
claim  that  appendicitis  is  a  purely  surgical  disease,  and  who  resort 


724 


APPENDICITIS. 


invariably  to  the  knife  as  soon  as  the  disease  is  detected.  The  men 
who  hold  and  defend  this  view  argue  that  if  an  early  diagnosis  is 
made  and*an  operation  promptly  performed,  the  chances  for  life  are 
better  than  under  conservative  treatment  and  late  operations,  should 
subsequent  complications  make  them  necessary.  Such  an  argu- 
ment is  contradicted  in  the  most  forcible  manner  by  the  well-known 
clinical  fact  that  from  80  to  85  per  cent,  of  all  cases  of  acute 
appendicitis  recover  under  judicious  medical  treatment.  On  the 
other  hand,  the  claim  can  again  be  made  that  of  these  cases,  an 
unknown  percentage  is  hable  to  suffer  from  subsequent  attacks. 
There  can  be  but  little  doubt  that  a  person  who  has  passed  through 
an  attack  of  appendicitis  is  predisposed  to  subsequent  attacks.  The 
percentage  of  those  who  suffer  relapses  remains  undetermined,  but 
every  practitioner  has  seen  no  inconsiderable  number  of  cases  where 
patients  remained  in  perfect  health  throughout  the  remainder  of  their 
lifetimes,  so  far  as  the  appendix  Avas  concerned.  I  have  seen  my 
share  of  cases  of  acute  appendicitis  recover  completely  and  perma- 
nently under  medical  treatment.  It  has  been  my  experience  that  re- 
lapses are  more  likely  to  occur  in  the  more  chronic  and  milder  forms 
of  appendicitis,  including  the  catarrhal  and  obliterating  varieties. 
The  greatest  doubt  in  the  mind  of  the  conscientious  physician  arises 
when  confronted  by  a  case  of  acute  appendicitis  during  the  first  at- 
tack, and  attended  by  stormy  symptoms.  It  is  in  such  cases  that 
careful  observation  and  good  judgment  are  required  to  determine 
what  to  do  and  to  decide  when  to  operate  in  case  the  medical  treat- 
ment is  deemed  inadequate  to  meet  the  existing  indications.  The 
medical  treatment,  however,  has  an  important  place  in  the  manage- 
ment of  every  case  of  appendicitis,  and  shoidd  7iever  be  ignored. 

A  diagnosis  of  appendicitis  having  been  made,  the  first  thing 
that  suggests  itself  is  to  place  the  .patient  upon  an  appropriate  diet. 
Solid  food  of  any  kind  must  be  absolutely  forbidden,  and  hquid  food 
reduced  to  a  minimum  ;  in  fact,  for  the  first  few  days  it  is  advisable 
to  abstain  entirely  from  stomach  feeding.  If  vomiting  is  a  con- 
spicuous symptom,  nothing  but  cold  or  hot  water,  in  small  quanti- 
ties frequently  repeated,  or  ice  pills  should  be  given  to  quench  the 
thirst.  If  nothing  is  retained  by  the  stomach,  normal  saline  solu- 
tion can  be  administered  by  the  rectum  or  by  subcutaneous  infu- 
sion. So  long  as  the  stomach  remains  irritable  and  the  temperature 
continues  high,  even  liquid  food  will  do  more  harm  than  good. 
Kumiss,  milk-whey,  barley-  or  rice-water,  and  thin  flour  soup  will 
be  retained  more  readily  than  any  other  kind  of  liquid  food,  and 
should  be  given  the  preference  over  milk  and  broths  as  articles  of 
diet  during  the  acute  stage.  The  appendix  being  a  part  of-  the  in- 
testinal canal,  it  is  important  to  influence  favorably  peristaltic  action 
by  limiting  the  diet  to  articles  of  food  that  are  digested  and  absorbed 
in  the  upper  portion  of  the  digestive  tract.  Much  harm  is  done  by 
adrninistering  food  that  should  be  withheld,  under  the  belief  that  the 
patient's    failing    strength    demands    it.      Instead  of  benefiting  the 


TREATMENT.  721; 


patient,  reckless  feeding  aggravates  the  disease  and  increases  the 
danger  from  perforation  and  peritonitis.  Much  has  been  said  in 
favor  of  and  against  the  use  of  laxatives  in  the  treatment  of  ap- 
pendicitis. A  laxative  is  a  two-edged  sword  that  must  be  handled 
with  care  in  the  treatment  of  this  disease.  Laxatives  must  never  be 
given  if  there  are  any  indications  that  perforation  has  taken  place 
If  perforation  and  gangrene  can  be  excluded  and  the  bowels  are  con- 
stipated, a  laxative  is  indicated  as  soon  as  a  diagnosis  of  appendicitis 
can  be  made.  The  best  laxative  is  castor  oil  in  tablespoonful  doses 
ever\'  three  hours  until  the  bowels  move  freely.  Some  physicians 
prefer  to  combine  it  with  olive  oil,  claiming  that  the  latter  is  a  sooth- 
ing application  to  the  inflamed  surface.  If,  after  the  second  or 
third  dose,  the  desired  effect  is  not  produced,  a  rectal  enema,  not  to 
exceed  a  quart,  and  containing  besides  soap  two  tablespoonfuls  of 
castor  oil  or  glycerin,  should  be  used  to  aid  the  laxative  in  pro- 
cunng  a  free  movement  of  the  bowels.  ///  the  absence  of  positive 
indications  the  evacuation  of  the  intestinal  canal,  and  especially  the 
cecum,  during  the  early  stages  of  the  disease  is  one  of  the  most  im- 
portant therapeutic  resources.  Free  catharsis  acts  beneficially  not 
only  by  eliminating  pathogenic  bacteria  from  the  seat  of  the  disease, 
but  also,  at  the  same  time,  is  the  best  possible  means  to  secure  for 
the  inflamed  part  what  is  so  much  needed— rest,  by  quieting  the 
intestinal  peristalsis. 

Opium,  the  remedy  employed  so  freely  and  constantly  in  the 
treatment  of  peritonitis  but  a  few  years  ago,  is  used  to-day  with  the 
greatest  reserve,  especially  during  the  beginning  of  the  attack. 
Many  physicians  are  entirely  oppcsed  to  any  kind  of  opiates  in  the 
treatment  of  appendicitis.  The  objections  to  the  routine  use  of 
opium  are  well  founded.  This  drug  and  all  of  its  preparations 
aggravate  the  intestinal  paresis,  increase  the  tympanites,  and  by  so 
doing  favor  the  development  of  pathogenic  microbes  and  their 
migration  through  the  paretic  intestinal  wall.  There  is,  however, 
one  well-defined  and  clear  indication  for  the  u.se  of  the  opium,  and 
that  is  perforation.  One  of  the  mo.st  important  agents  for  the  dif- 
fusion of  .septic  material  in  the  peritoneal  cavity  after  perforation 
has  taken  place  is  intestinal  peristalsis.  The  moment  perforation  has 
taken  place,  all  influences  must  be  brought  to  bear  to  quiet  intestinal 
peristalsis  and  to  limit  the  escape  of  .septic  material  into  the  free  /peri- 
toneal cavity.  These  objects  are  attained  more  nearly  by  abstaining 
from  the  use  of  laxatives  and  .stomach  feeding  and  by  resorting  to 
opium,  than  by  any  other  known  methods  of  treatment.  By  secur- 
ing rest  for  the  intestines  and  the  perforated  organ  the  most  favor- 
able conditions  are  created  for  the  localization  of  the  infection  and 
protection  of  the  hcit  peritoneal  cavity  by  plastic  exudates  around 
the  focus  of  primary  invasion. 

Perforative  peritonitis  is  a  surgical  affection,  and  should  be 
regarded  and  treated  as  such  the  moment  the  accident  has  taken 
place,  but,  unfortunately,  the  j)hysician  is  not  always  summoned  at 


726 


APPENDICITIS. 


this  opportune  time,  and  a  certain  length  of  time  must  necessarily 
elapse  before  the  necessary  preparations  for  the  operation  can  be 
made.  This  time  must  be  utilized  to  the  utmost  advantage  in 
securing  the  benefits  of  rational  medical  treatment. 

Operative  Treatment. — Even  the  most  conservative  surgeons 
are  fully  in  accord  with  the  progressive  physicians  advocating  early 
operative  interference  in  perforative  and  gangrenous  appendicitis. 
Hesitation  in  such  cases  only  aggravates  the  danger,  and  delayed 
operations  have  often  to  deal  with  complications  beyond  the  reach 
of  successful  surgery.  The  difficulty  met  here  is  an  early  positive 
diagnosis.  If  we  were  in  a  position  to  recognize,  by  infallible  signs 
or  symptoms,  the  existence  of  a  perforation,  there  would  be  little 
difficulty  in  convincing  the  patient  and  the  profession  of  the  neces- 
sity of  an  immediate  operation.  It  is  this  uncertainty  in  the  diag- 
nosis during  the  early  stages  of  the  disease  that  is  responsible  for  many 
unnecessary  operations  on  the  one  hand,  and  dangerous  delays  on  the 
other.  Perforative  appendicitis  should  be  treated  by  laparotomy 
within  tzventyfour  hours  after  the  accident  has  occurred,  because  if 
this  period  of  time  is  allozved  to  elapse  without  active  interference , 
Giving  to  the  uncertainty  of  the  diagnosis  or  unavoidable  delay,  the 
peritoneal  infection  may  have  reached  an  extent  beyond  the  limits  of  a 
successfid  operation. 

Early  Operations  for  Appendicitis. — By  early  operations  should 
be  understood  a  resort  to  laparotomy  within  twenty -four  hours  after 
a  first  attack  of  appendicitis.  It  is  important  to  make  a  distinction 
between  early  and  late  operations  from  a  pathologic  as  well  as  a 
technical  standpoint.  If  the  operation  is  performed  within  the  limit 
of  time  named,  no,  or  but  slight,  adhesions  are  found,  there  will  be 
no  pus,  and  the  mesentery  and  base  of  the  appendix  will  be  in  a 
favorable  condition  for  amputation  and  safe  disposal  of  the  stump. 
Early  operations  are  always  made  in  a  typical  manner — that  is,  the 
free  peritoneal  cavity  is  invariably  opened  and  the  diseased  appendix 
is  removed  through  a  comparatively  small  opening.  In  all  early 
operations  the  appendix  can  be  removed  without  any  special  diffi- 
culties, and  by  doing  so  the  diseased  organ  and,  with  it,  the  primary 
source  of  infection  are  eliminated.  The  abdomen  is  opened  by 
McBurney's  muscle-splitting  method,  which  usually  secures  ample 
room  for  the  removal  of  the  inflamed  organ.  The  first  incision  is 
made  about  four  inches  in  length,  two  inches  from  Poupart's  liga- 
ment, and  parallel  with  the  fibers  of  the  external  oblique  muscle, 
and  equidistant  from  McBurney's  line.  The  external  oblique  mus- 
cle is  next  divided  by  penetrating  the  muscle  with  the  point  of  the 
scalpel  in  the  upper  angle  of  the  wound,  and  cutting  in  the  direc- 
tion of  the  fibers  until  the  lower  angle  is  reached.  The  incision  is 
made  with  greater  accuracy  if  the  knife  is  followed  by  the  tip  of  the 
left  index-finger,  thus  spreading  the  wound  as  the  incision  is  en- 
larged. The  margins  of  the  wound  are  now  retracted  sufficiently 
to  expose  the  internal   oblique   to  the  requisite  extent.      With  the 


EARLV    OPERATIONS    FOR    APPENDICITIS. 


727 


knife  and  a  blunt  dissector  an  opening  is  made  in  the  middle  of  the 
wound  in  the  internal  oblique  muscle,  in  the  direction  of  its  fibers, 


Fig.  467. — Opening  the  abdomen  for  the  removal  of  the  appendix  by  McBurney's  mus- 
cle-splitting incision.      External  incision. 


Kig.  46S. — .Manner  of  cutting  the  extirrnal  oblifinc  nniscjc  in  the  direclion  of  its  (ibers. 

when   the  wound   is  enlar^^ed    by  in.scrting  the  tips   of  both  fore- 
fingers, which  are  then  used   in   dilating   the  wound  to  the  desired 


728 


APPENDICITIS. 


extent.     With  blunt  retractors  the  margins  of  the  wound  in  the 
internal  oblique  are  then   retracted,  and  the   remaining  structures 


Fig.  469. — Internal  oblique  muscle  divided  in  the  direction  of  its  fibers,  largely  by 
the  use  of  blunt  instruments  and  index-fingers  ;  remaining  structures  ready  to  be  incised 
between  two  dissecting  forceps. 


F'g-  470- — Incision  of  transversalis  fascia  and  peritoneum  between  two  dissecting  forceps. 


divided  between  two  dissecting  forceps.      Care  is  necessary  in  com- 
pleting the  incision  not  to  include  in  the  grasp  of  the  forceps  an 


EARLY    OPERATIONS    FOR    APPENDICITIS. 


729 


intestinal  loop,  an  accident  that  occurred  in  one  of  the  cases  in  my 
practice.  As  soon  as  the  peritoneal  cavity  has  been  opened,  the 
omentum  usually  presents  itself  in  the  wound.  By  inserting  the 
tips  of  the  index-fingers  the  peritoneal  opening  is  enlarged  suffi- 
ciently to  locate,  bring  forward,  isolate,  and  remove  the  diseased 
appendix. 

One  of  the  great  advantages  of  McBurney's  muscle-splitting 
incision  is  that  only  slight  damage  is  inflicted  upon  the  muscular 
part  of  the  abdominal  wall,  and  consequently,  if  the  wound  is 
properly    closed,    there     is    very    little     liability    incurred     to     the 


Fig.  471. — Tying  off  the  mesenteriolum  (McBurney). 


formation  of  a  ventral  hernia  as  a  remote  consequence  of  the 
operation  ;  this  latter  can  not  be  said  of  operations  in  which  the 
incision  is  made  by  cutting  the  abdominal  muscles  free!)',  without 
regard  to  the  direction  of  their  fibers.  The  opening,  made  as 
described,  is  generally  large  enough  in  recent  cases  for  the  radical 
removal  of  the  di.seased  appendix.  The  next  step  in  the  operation 
con.si.sts  in  finding  the  appendix.  This  ma)-  be  easy  or  difficult, 
according  to  the  location  of  the  organ.  If  the  appendix  is  in  front 
of  the  cecum,  it  is  readily  found  and  easy  of  access.  If  it  is  located 
to  the  inner  or  under  .side  of  the  cecum,  which  i.s  more  frequently 
the  ca.se,  it  rcfjuires  more  time  and  patience  to  expose  it. 


730 


APPENDICITIS. 


In  searching  for  the  appendix  it  is  necessary  first  to  find  and 
identify  the  cecum,  the  longitudinal  band  in  front  of  which  serves  as 
an  unerring  guide  to  the  base  of  the  organ.  The  longitudinal  band 
is  not  only  relied  upon  in  serving  as  a  guide  to  the  cecal  end  of  the 
appendix,  but  it  also  serves  as  a  reliable  landmark  in  differentiating 
between  the  large  and  a  loop  of  the  small  intestine.  Should  a  coil 
of  small  intestine  present  itself  on  opening  the  peritoneal  cavity,  it  is 
pushed,  with  the  omentum,  toward  the  median  line,  and  is  held  out 
of  the  way  during  the  remaining  steps  of  the  operation  by  a  strip 
of  aseptic  gauze  securely  fastened  in  the  jaws  of  a  hemostatic 
forceps.  As  soon  as  the  cecum  is  found,  the  longitudinal  band  is 
looked  for  and  followed  in  the  direction  of  the  caput  caeci,  which 
always  leads  to  the  base  of  the  appendix.  As  soon  as  the  ap- 
pendix has  been  located,  the  free  peritoneal  cavity  is  protected  by 
packing  with  a  strip  of  sterile  .gauze,  again  secured  on  the  out- 
side with  the  forceps.  It  is  necessary  to  keep  the  gauze  packing  in 
place  until  the  appendix  has  been  removed  and  the  stump  properly 
disposed  of,  to  prevent  peritoneal  contamination  by  extravasation 
from  the  perforation  during  the  manipulation  of  the  appendix  in 
performing  this  part  of  the  operation,  and  later  from  the  cut  end  of 
the  stump.  After  the  appendix  has  been  made  accessible  from  base 
to  apex,  its  mesentery  is  tied,  preferably  with  fine  silk.  The  loca- 
tion of  the  principal  artery  from  the  free  border  of  the  mesenteriolum 
varies  greatly,  as  well  as  its  size  and  length.  If  the  mesenteriolum 
is  short,  one  ligature  applied  near  the  base  of  the  appendix  will  suf- 
fice ;  if  it  is  long,  two  ligatures  maybe  required.  The  tissues  close 
to  the  appendix  are  tunneled  either  with  locked  hemostatic  forceps, 
which  are  then  used  in  carrying  the  ligature  through  the  opening,  or 
the  arteiy  needle,  armed  with  fine  silk,  is  used  in  applying  the  liga- 
ture. The  tying  must  be  done  slowly  and  in  steady  jerks,  so  as  to 
make  the  ligature  cut  its  way  deeply  into  the  tissues  in  order  efficiently 
to  secure  the  vessels  and  to  guard  against  slipping  of  the  ligature. 
The  mesentery  is  cut  close  to  the  appendix  from  tip  to  base,  when 
the  appendix  is  ready  for  amputation. 

Three  methods  of  amputation  recommend  themselves  with  spe- 
cial reference  to  proper  disposal  of  the  stump.  The  simplest 
method  is  by  cutting  through  the  base  of  the  appendix  near  the 
cecal  wall  with  one  stroke  of  the  scissors,  as  advocated  and  so  ex- 
tensively practised  by  Deaver.  The  head  of  the  cecum  just  above 
the  base  of  the  appendix  is  grasped  with  the  thumb  and  index- 
finger  of  the  hand  in  such  a  way  as  to  prevent  fecal  extravasation 
through  the  cecal  opening  until  the  wound  is  securely  sutured,  and 
also  for  the  purpose  of  fixing  the  cecum  during  the  amputation  of 
the  appendix  and  suturing  of  the  resulting  visceral  wound.  The 
small  wound  in  or  near  the  cecal  wall  is  closed  by  sutures  of  fine 
silk  inserted  with  an  ordinary  sewing  needle  in  the  same  manner  as 
in  closing  any  other  intestinal  wound  by  suturing.  Usually  two 
Czerny  and  from  three  to  six   Lembert  sutures  will   suffice.      This 


EARLY    OPERATIONS    FOR    APPENDICITIS. 


71^ 


method  of  removing  the  appendix  is  a  most  excellent  one.  and 
should  be  followed  in  all  cases  in  which  the  condition  of  the  tissues 
can  be  relied  upon  in  furnishing  the  necessary  support  for  the 
sutures. 

The  next  method  consists  in  making  a  peritoneal  circular  cuff, 
with  which  the  wound  can  be  covered  after  the  amputation  of  the 
appendix— in  other  words,  subserous  amputation  of  the  appendix. 
A  circular  incision  is  made  through  the  peritoneal  coat,  half  an  inch 
from  the  cecum,  and  with  dissecting  forceps  the  peritoneum  is 
reflected  as  far  as  the  cecum,  where  the  appendix  is  tied  with  fine 
catgut  at  the  base  of  the  peritoneal  cuff,  and  amputated  at  a  safe 
distance  below.  The  point  of  an  aseptic  toothpick  is  dipped  into 
pure  carbolic  acid   and  applied   to    the   mucosa  below  the  ligature, 


I'''g-  472- — Appendix  amputated,  and  purse-string  suture  in  position. 


and  after  the  excess  of  acid  has  been  removed  by  holding  a  small 
gauze  sponge  for  a  {^vi  moments  against  the  cauterized  surface,  the 
peritoneal  cuff  is  .-sutured  over  the  .stump  with  two  or  three  'firm 
catgut  sutures,  which  arc  tied  after  inverting  the  margins  of  the 
cuff.  I  have  dealt  with  the  disea.sed  appendix  a  sufficient  nimiber 
of  times  to  have  become  convinced  of  the  .safety  of  this  procedure. 
The  third  and  most  recent  method  of  amputation  of  tiic  appen- 
dix that  deserves  the  confidence  of  the  profession  is  the  one  dcvi.sed 
by  Doyen.  Doyen's  method  consi.sts  in  grasping  the  ba.se  of  the 
appendix  with  a  pair  of  .strong  hemostatic  forceps,  and  making  suffi- 
cient pressure  to  crush  the  muscular  and  mucous  coats,  leaving  a 
depression  where  the  ligature  of  catgut  is  applied  which  includes 
only  the  .serous  coat.      The  appendix   is  amputated  below  the  liga- 


732 


APPENDICITIS. 


ture,  and  the  circular  strip  of  mucous  membrane  in  the  stump  is 
either  excised  or  cauterized  with  carbolic  acid.  As  a  matter  of  ad- 
ditional safety,  the  stump  is  buried  by  three  or  four  Lembert  sutures 
of  fine  silk.  Very  often  the  stump  of  the  mesenteriolum  can  be 
utilized  as  a  covering  for  the  stump  by  fastening  it  over  the  stump 
with  two  or  three  seromuscular  sutures  of  fine  silk.  Another  safe 
method  of  burying  the  stump  is  by  the  purse-string  suture.  With 
a  needle  armed  with  fine  silk,  fine  seizures  are  made,  including  all  the 
coats  minus  the  mucosa,  when,  on  tying  the  suture,  the  stump  is 
covered  by  drawing  the  serous  surfaces  over  it. 

Any  of  these  three  methods  is   applicable  in  early  operations 
for  the  removal  of  the  appendix,  and  in  making  the  selection  the 


Fig.  473. — Stump  buried  by  tying  of  the  purse-string  suture. 


surgeon  will  be  guided  largely  by  the  condition  of  the  tissues  at  the 
site  of  amputation.  In  recent  cases  of  appendicitis  subjected  to 
laparotomy,  flushing  of  the  exposed  part  of  t^ie  peritoneal  cavity, 
even  in  the  event  that  perforation  has  taken  place,  is  not  only  super- 
fluous, but  harmful.  If  peritoneal  contamination  has  taken  place, 
from  a  dram  to  half  an  ounce  of  peroxid  of  hydrogen  is  poured 
into  the  space  from  which  the  appendix  was  removed,  previously 
well  walled  off  by  gauze  packing,  after  which  the  surface  is  care- 
fully cleansed  by  mopping  with  a  gauze  sponge. 

In  all  operations  for  perforative  appendicitis  drainage  is  posi- 
tively indicated,  as  we  have  no  assurance  that  any  amount  of  local 
disinfection  has  succeeded  in  eliminating  the  pyogenic  infection. 
The  gauze  strip  or  strips  used  in  protecting  the  peritoneal   cavity 


INTERMEDIATE    OPERATIONS    FOR    APPENDICITIS.  733 

against  infection  are  brought  into  the  lower  angle  of  the  wound, 
and,  as  an  additional  precaution,  a  tubular  drain  is  inserted  into  the 
place  occupied  by  the  appendix,  which  is  secured  on  the  surface  of 
the  wound  with  a  large  safety-pin.  The  peritoneal  wound  is  sutured 
with  fine  catgut,  leaving  sufficient  space  for  the  combined  tubular 
and  capillary  drain.  The  external  oblique  muscle  is  sutured  sep- 
arately to  the  same  extent  with  coarser  catgut.  The  deep  sutures 
of  silkworm-gut  include  ever\-thing  outside  of  the  peritoneum,  and 
are  tied  as  far  as  the  drainage  opening ;  the  two  lowest  sutures  are 
left  in  position  untied,  but  knotted  at  the  end,  until  after  the  removal 
of  the  drains,  when  the  remainder  of  the  wound  is  closed  by  tying 
the  secondary  sutures.  McBurney's  incision  can  be  drained  for  two 
or  three  days  with  hardly  any  risk  of  the  subsequent  formation  of  a 
ventral  hernia  if  the  wound  is  closed  by  secondary  suturing  after 
the  removal  of  the  drain. 

A  large  hygroscopic  sterile  dressing  is  necessary  if  the  wound 
is  drained,  and  the  dressing  is  held  in  place  by  one  or  two  broad 
strips  of  adhesive  plaster  and  gauze  roller.  If  the  wound  is  sutured 
throughout,  a  small  dressing  similarly  retained  or  an  iodoform  gauze 
collodion  crust  will  protect  the  wound  against  postoperative  in- 
fection. 

It  is  a  uniform  rule,  to  which  I  make  no  exceptions,  for  me  to 
enforce  the  recumbent  position  for  four  weeks  after  the  operation, 
and,  as  an  additional  precaution  against  the  formation  of  a  ventral 
hernia,  I  provide  my  patients  before  resuming  the  erect  position  with 
a  well-fitting  abdominal  bandage,  which  is  directed  to  be  worn  dur- 
ing the  day  for  at  least  three  months. 

Intcnncdiatc  Operations  for  Appendicitis. — If,  during  a  first  grave 
attack  of  appendicitis,  a  radical  operation  is  not  performed  within 
the  first  twenty-four  or  forty-eight  hours,  complications  are  most 
likely  to  occur  the  presence  of  which  may  demand  an  operation  as 
a  life-saving  measure.  The  two  complications  that  most  frequently 
necessitate  a  recour.se  to  an  intermediate  operation  during  the  active 
progress  of  the  disea.se  are  progressive  septic  peritonitis  and  abscess 
formation.  If  the  primary  attack  is  mild  from  the  beginning  or  is 
made  harmless,  as  far  as  life  is  concerned,  by  the  encapsulation  of 
the  appendix  by  a  localized  plastic  peritonitis,  an  intermediate  oper- 
ation is  contraindicated.  If,  on  the  other  hand,  the  .symptoms 
become  progressively  aggravated  and  life  is  placed  in  jeopardy  from 
a  rapidly  spreading  septic  peritonitis  or  the  formation  of  an  intra- 
peritoneal abscess,  an  operation  becomes  a  matter  not  of  choice,  but 
of  neces.sity.  Both  the  general  and  local  conditions  combine  in 
frequently  modifying  the  technic  of  early  o[)eration.  The  prostra- 
tion of  the  patient  and  the  tympanites  make  it  often  neccs.sary  to 
complete  the  operation  as  quickly  as  possible. 

The  main  objects  of  the  intermediary  operations  are  to  reach  the 
focus  of  infection,  establish  free  drainage,  and  disinfect  the  area  of 
infection.     Attempts  to  find  and  remote  the  diseased  appendix  under 


734 


APPENDICITIS. 


such  circumstances  are  justifiable  only  when  this  can  be  done  without 
increasing  the  danger  from  the  extension  of  perito?ieal  infection.  The 
leading  indication  in  such  cases  is  to  save  life  by  arresting  or  limit- 
ing the  intraperitoneal  infection.  To  accomplish  this,  the  most  direct 
route  to  the  seat  of  infection  must  be  followed,  and  the  peritoneal 
cavity  beyond  the  limits  of  the  infection  must  be  protected  against 
contamination,  as  far  as  possible,  by  mechanical  and  chemic  means. 
If,  on  opening  the  abdominal  cavity  in  the  usual  manner  over 
the  appendix,  it  is  found  that  the  peritoneal  surface  has  become  ex- 
tensively involved  and  there  are  no  indications  of  limitation  of  the 

infection  by  plastic  ad- 
hesions, the  efforts  must 
"^  be  directed  particularly 
to  limiting  further  ex- 
tension of  the  infective 
process.  If  the  perfor- 
ated or  gangrenous  ap- 
pendix can  be  reached 
without  any  special  diffi- 
culty, it  is  removed  in 
the  manner  previously 
described.  The  opening 
in  the  abdomen  made  by 
muscle  splitting  is  often 
too  small  to  deal  effi- 
ciently with  the  perito- 
nitis, in  which  case  it  is 
enlarged  to  the  requisite 


length. 


Washing  out  of 


Fig-  474- — Long  incision  for  appendicitis  in  compli- 
cated cases  (Kocher). 


the  accessible  area  of  in- 
flamed peritoneal  cavity 
with  a  hot  saline  or 
Thiersch's  solution  is 
recommended  by  many 
surgeons  whose  experi- 
ence in  this  department 
of  surgical  work  is  ex- 
tensive. If  the  peritoni- 
tis has  resulted  in  intestinal  paresis  and  extensive  tympanites,  evacu- 
ation of  the  distended  intestinal  coils  is  an  absolute  necessity.  This 
can  be  done  in  one  of  two  ways  :  (i)  By  the  formation  of  an  intes- 
tinal fistula  by  a  left  inguinal  enterostomy.  (2)  By  visceral  incision 
of  the  distended  intestine,  pouring  out  of  its  contents,  injecting  into 
the  bowel  a  saturated  solution  of  sulphate  of  magnesia  (one  ounce), 
suturing  of  wound,  and  returning  the  bowel  into  the  peritoneal 
cavity. 

If  it  is  decided  to  relieve  the  intestinal  distention  by  the  forma- 
tion of  a  temporary  intestinal  fistula,  the  left  groin  should  be  selected, 


LATE    OPERATIONS    FOR    APPENDICITIS.  735 

in  order  to  bring  the  fecal  fistula  far  enough  away  from  the  opera- 
tion wound  to  protect  it  tVom  subsequent  infection  from  this  source, 
as  the  first  incision  is  ahvajs  needed  for  free  drainage.  If  the 
peritonitis  has  become  diffuse,  extensive  tubular  and  gauze  drainage 
is  required.  It  is  advisable  in  such  cases  to  leave  the  abdominal 
incision  unsutured,  relying  upon  gauze  in  preventing  prolapse  of 
the  small  intestine  and  cecum.  A  hot  moist  antiseptic  compress 
over  the  wound  answers  a  better  purpose  than  a  dry  dressing. 
Active  stimulation  is  necessary  to  support  the  flagging  circulation 
and  to  combat  the  general  effect  of  the  septic  infection.  If  the  in- 
fection is  more  localized  and  has  resulted  in  the  formation  of  pus, 
the  principal  object  of  the  operation  is  to  furnish  a  free  outlet  for 
the  inflammatory  product.  The  use  of  the  exploring  syringe  in 
locating  the  abscess  through  the  intact  abdominal  wall  is  unreli- 
able and  often  dangerous.  The  exploring  needle  is  occasionally 
required  in  locating  an  abscess  after  the  abdomen  has  been  opened, 
and  can  then  be  used  without  risk  ;  the  information  derived  from 
its  employment  in  this  manner  is  often  of  great  value  in  guiding 
the  surgeon  in  finding  and  opening  the  abscess  cavity.  If  the  ab- 
scess is  found  immediately  underneath  the  abdominal  wall,  the  oper- 
ation is  a  very  easy  one,  and  unless  the  appendix  can  be  found  and 
removed  without  exposing  the  free  peritoneal  cavity  to  risks  of  infec- 
tion, it  is  completed  by  evacuating  the  contents  of  the  abscess  cavit}', 
pouring  into  it  peroxid  of  h}-drogen,  and  establishing  free  tubular 
drainage.  The  drain  should  be  at  least  the  size  of  the  index-finger, 
well  fenestrated,  and  secured  with  a  safety-pin.  A  dry  sterile  dress- 
ing is  applied  as  a  protection  against  mixed  infection.  If  suppura- 
tion continues,  daily  disinfection  with  peroxid  and  irrigation  of  the 
cavity  with  a  mild  warm  antiseptic  solution  constitute  the  most  im- 
portant part  of  the  after-treatment.  Such  cavities  often  heal  in  a  short 
time,  and  permanently,  even  if  the  appendix  is  not  removed.  A 
persistent  fistula,  with  or  without  the  escape  of  intestinal  contents, 
indicates  a  communication  with  the  interior  of  the  appendix  as  the 
result  of  a  perforation  or  partial  sloughing,  and  may  require  a 
secondary  operation  for  the  removal  of  the  organ. 

If,  on  opening  the  abdomen  through  the  free  peritoneal  cavity, 
the  abscess  is  found  behind  the  cecum,  the  surgeon  has  the  choice 
between  two  procedures  : 

1.  Packing  the  wound  with  gauze  in  such  a  way  that  in  the 
course  of  a  few  days  the  free  peritoneal  cavity  is  shut  out  from  the 
wound  by  adhesions,  and  the  abscess  behind  the  cecum  is  made 
readily  accessible  to  a  .second  extraj)eritoncal  operation  (Sonnenl)urg). 

2.  The  peritoneal  cavity  is  protected  by  gauze,  which  is  allowed 
to  remain,  and  the  abscess  is  at  once  opened  and  drained.  In  such 
cases  the  appendix  should  not  be  looked  for,  much  less  should  attempts 
be  made  to  remo%>e  it.  Prolonged  drainage  always  creates  a  predis- 
position to  the  stib.sequent  formation  of  a  ventral  hernia. 

Late  Operations  for  Appendicitis. — These  operations  include  ail 


71^ 


APPENDICITIS. 


cases  in  which  abscesses  need  to  be  opened  weeks  and  months  after 
the  acute  symptoms  have  subsided,  and  in  relapsing  appendicitis.  In 
the  former  case,  if  it  is  possible,  the  abscess  is  always  opened  and 
drained  by  the  extraperitoneal  route,  reserving  the  removal  of  the 
diseased  appendix  for  a  secondary  operation  should  this  become 
necessary  by  persistence  of  a  fistulous  tract  or  by  recurring  attacks 
of  pain. 

Operative  inteiference  is  always  justifiable  in  relapsing  appen- 
dicitis after  the  second  attack.  The  operation  is  easier,  safer,  and 
more  successful  if  it  is  performed  after  the  cessation  of  acute  symp- 
toms— that  is,  during  the  interval.  It  may  be  easy  or  extremely 
difficult.  If  the  attacks  point  to  the  catarrhal  form  of  the  disease, 
the  appendix  is  usually  found  enlarged,  very  muscular,  free,  and 
can  be  removed  without  any  special  difficulty,  regardless  of  its 
location.  If  the  attacks  appear  in  the  form  of  circumscribed  plastic 
peritonitis,  the  appendix  is  generally  found  embedded  in  a  mass  of 
scar  tissue,  and  its  removal  becomes  an  extremely  difficult  task.  It 
is  in  such  cases  that  I  have,  for  a  ?iumber  of  years,  resorted  to  sub- 
serous enucleation  of  the  organ.  This  is  done  by  first  reaching  its 
cecal  end,  when  the  peritoneal  coat  is  incised  in  the  long  axis  of 
the  organ,  and,  with  Kocher's  director  or  a  pair  of  blunt-pointed 
scissors,  the  enucleation  is  made  from  the  base  to  the  tip  of  the 
appendix.  Hemorrhage  is  avoided  by  incising  the  peritoneum 
opposite  the  mesenteric  border.  With  a  fine  catgut  ligature  the 
enucleated  appendix  is  ligated  near  the  cecum,  and  amputated  at  a 
safe  distance  below  the  ligature.  The  exposed  mucous  membrane 
of  the  stump  is  cauterized  with  carbolic  acid,  and  the  peritoneal 
envelop  is  sutured  over  the  stump  with  two  or  three  fine  catgut 
sutures. 

In  all  operations  for  relapsing  appendicitis  the  peritoneal  cavity 
is  protected  against  infection  by  gauze  packing,  and  this  is  particu- 
larly necessary  in  cases  in  which  small  peri-appendicular  abscesses 
are  exposed  during  the  isolation  or  enucleation  of  the  appendix. 

I  have  come  to  the  conclusion  that  surgical  interference  is  at- 
tended by  more  than  the  usual  amount  of  risk  in  cases  in  which 
the  clinical  history  points  to  abscess  formation  and  rupture  of  the 
abscess  into  the  cecum  during  the  first  attack.  Such  cases  should 
not  be  interfered  with  unless  the  urgency  of  the  symptoms  demands 
it,  because  the  intrinsic  tendency  is  to  an  ultimate  permanent  re- 
covery, and  the  risks  incident  to  the  operation  are  such  as  to  cau- 
tion the  surgeon  against  hasty  action.  In  all  operations  in  which 
pus  is  found,  disinfection  of  the  bed  occupied  by  the  appendix  and 
free  drainage  for  a  day  or  two,  at  least,  are  urgently  indicated. 


CHAPTER  XIX. 

INTESTINAL  OBSTRUCTION. 

A  SURGICAL  subject  of  mutual  interest  both   to   the  physician 
and  surgeon,  but  more  particularly  to  the  general  practitioner   is 
intestmal  obstruction.      The  pathologic  and  mechanical   conditions 
that  may  mtercept  the  fecal  current,  in  part  or  completely,  are  so 
manifold,  the  symptoms  are  often  so  obscure,  and  the  treatment  on 
the  whole,  is  so   unsatisfactory,  that  such  cases  nearly  always  give 
rise  to  doubt,  misgivings,  and  not  infrequently  to  hesitation  in  the 
minds  of  the    most    experienced    practitioners.      Every    one    who 
undertakes  the  treatment  of  a  case  of  acute  intestinal  obstruction 
feels  most  keenly  the  responsibility  that  he  assumes,  the  difficulties 
encountered  in  making  an  early  pathologic  and  anatomic  diagnosis 
and   the   uncertainty  that   awaits   the  fate  of  his  patient.      It  is  in 
cases  of  this  kind  that  we  are  always  willing  and  anxious  to  avail 
ourselves,  where  it  can  be  done,  of  the  knowledge,  diagnostic  skill 
and   sound  advice  of  one  or  more  of  our  colleagues,  to  aid  us  in 
correctly  interpreting  the  symptoms  at  the  bedside,  and  in  adopting 
a  course  of  treatment  best  calculated  to  meet  the  pathologic  condi- 
tions that  have  interfered  with  or  completely  suspended  function  in 
a  certain  part  of  the  intestinal  tract.      The  general  practitioner  in 
isolated  communities,  far  away  from  counsel  and  skilled  assistance, 
realizes  the    responsibility  of  his  position  when    confronted   by   a 
case  of  acute  intestinal  obstruction.      He  knows  that  the  ultimate 
result  always  depends  on  an  early  correct  diagnosis  and  a  rational 
treatment  based  on  the  same.      How  many  professional   men  are 
there  who  are  willing  to  assume  the  sole  responsibility  in  such  a  case, 
and  who  are  in  possession  of  the  requisite  degree  of  moral  courage 
to  act  in  accord  with  their  convictions  ?     It  requires  courage  based 
on  knowledge  to  perform  laparotomy  in  a  case  of  acute  intestinal 
obstruction,    with    the    aid  of  a   lamp   or   by   candle  light,  in   the 
kitciien  or  in  a  small  bedroom,  without  skilled  assistance  ;  and  yet 
modern  surgery  makes  such  demands  on   the  general  practitioner, 
so  situated,  in  cases  in  which  death  would  be  the  inevitable  conse- 
quence without  operative  interference. 

The  importance  of  intestinal  obstruction  from  a  medical  as  well 
as  a  surgical  aspect,  and  the  difficulties  encountered  in  its  early 
diagnosis  and  rational  treatment  are  the  apologies  offered  for  gi\-ing 
this  chapter,  in  a  book  intended  for  the  general  i)ractitioner,  the 
prominence  that,  in  my  estimation,  it  de.serves. 

Frequency. — An  examination  of  the  statistics  of  Leichtenstern 
shows  that,  external  hernia;  and  malignant  tumors  being  excluded, 
47  737 


738  INTESTINAL    OBSTRUCTION. 

one  death  from  intestinal  obstruction  takes  place  in  every  300  to 
500  deaths  from  all  causes  in  hospital  practice.  This  statement  is 
based  upon  the  records  of  the  late  Dr.  Brinton,  of  London,  and  a 
number  of  large  hospitals  on  the  European  continent. 

Hilton  Fagge  has  shown,  from  an  examination  of  the  records  of 
4000  autopsies  in  Guy's  Hospital,  from  1854  to  1868,  that  54,  or 
about  %  of  I  per  cent.,  were  cases  of  intestinal  obstruction. 

Heusner,  from  his  own  investigations  regarding  the  frequency 
of  intestinal  obstruction,  maintains  that  annually  out  of  every  100,- 
000  individuals,  from  5  to  10  suffer  from  this  affection,  and  that  one 
out  of  every  300  to  500  deaths  is  attributable  to  this  cause.  These 
statistics  show  the  importance  of  intestinal  obstruction  in  its 
medical  and  surgical  relations,  and  it  is  eminently  proper  that  this 
subject  should  receive  the  most  careful  and  detailed  treatment  in  a 
work  on  emergency  surgery,  as  all  operations  for  intestinal  obstruc- 
tion come  within  the  legitimate  scope  of  emergency  work,  with  which 
every  general  practitioner  should  be  perfectly  familiar  and  compe- 
tent to  undertake. 

Intestinal  obstruction — ileus  of  the  German  authors — is  a  com- 
plete or  partial  arrest  of  the  intestinal  contents,  due  to  either  mechan- 
ical or  dynamic  causes.  In  mechanical  obstruction  the  lumen  of  the 
bowel  becomes  impermeable  by  impaction,  invagination,  twist,  con- 
striction, compression,  or  flexion — the  mechanical  causes  contrib- 
uting obstacles  to  the  passage  of  intestinal  contents  above  the  seat 
of  obstruction.  Dynamic  obstruction  is  produced  by  causes  (inflam- 
mation, defective  or  suspended  innervation,  muscular  atony)  that 
diminish  or  arrest  peristalsis  in  a  portion  of  the  intestinal  canal,  of 
greater  or  less  extent,  resulting  in  accumulation  of  the  intestinal 
contents  in  the  affected  part  of  the  bowel,  such  accumulation  then 
becoming  a  secondary  mechanical  cause  of  obstruction  by  aggra- 
vating the  existing  paretic  condition.  It  is  in  the  latter  class  of  cases 
that  medical  treatment  occasionally  proves  successful,  and  for  which 
surgical  treatment  offers  so  little  as  compared  with  intestinal  obstruc- 
tion caused  by  purely  mechanical  causes.  Mechanical  obstruction, 
if  not  relieved  in  time,  always  leads  to  dynamic  obstruction  by  over- 
distention  and  paralysis  of  the  intestinal  wall  above  the  obstruction, 
so  that  not  infrequently  a  partial  mechanical  obstruction  ultimately 
is  followed  by  complete  obstruction  due  to  dynamic  causes. 

For  diagnostic,  pathologic,  and  practical  reasons  the  classifica- 
tion of  intestinal  obstruction  into  acute  and  chronic  is  of  the  greatest 
importance.  The  mechanical  causes  that  give  rise  to  acute  intes- 
tinal obstruction  usually  affect  the  intestinal  canal  above  the  ileo- 
cecal valve,  while  the  reverse  is  the  case  in  chronic  obstruction. 
Recently  attention  has  been  called  to  embolism  and  thrombosis  of 
the  inferior  mesenteric  vessels  as  a  cause  of  acute  dynamic  obstruc- 
tion. Watson  has  collected  twenty-nine  cases,  three  of  which  came 
under  his  own  observation.  He  mentions  as  the  most  important 
symptoms  :    (i)    Colicky,  very  intense,  not  definitely  localized,  ab- 


ACUTE    INTESTINAL    OBSTRUCTION. 


739 


dominal  pain ;  (2)  bloody  diarrhea ;  (3)  subnormal  temperature. 
Vomiting,  if  present, — and  next  to  pain  it  is  the  most  frequent  symp- 
tom,— strengthens  the  diagnosis,  as  do  also  abdominal  distention 
and  marked  prostration  ;  but  the  first  two  or  three  symptoms,  when 
occurring  in  combination,  are  the  only  ones  that  can  be  called 
in  any  sense  characteristic.  Pain  is 
the  first  symptom  more  often  than 
any  other,  and  its  intense  character 
is  dwelt  on  by  several  authors.  In 
about  one-sixth  of  the  cases  that 
came  to  an  autops)'  the  examination 
showed  that  the  intestinal  lesion, 
gangrene,  was  sufficiently  limited 
and  well  defined  to  permit  of  a  suc- 
cessful resection  of  the  affected  part 
of  the  bowel. 

The  various  causes  that  lead  to 
intestinal  obstruction  will  be  alluded 
to  in  detail  in  the  discussion  of  the 
different  anatomic  and  pathologic 
forms  of  the  affection. 

Acute  Intestinal  Obstruction. 
— Acute  intestinal  ob.struction  oc- 
curs without  any,  or  with  ill-defined, 
premonitory  symptoms,  by  the  de- 
velopment of  a  group  of  symptoms 
almost  pathognomonic  of  this  dis- 
ease. The  sudden  arrest  of  the 
fecal  passage  is  followed  almost 
immediatel}'  by  violent  peristaltic 
action  of  the  bowel  above  the  seat 
of  obstruction  in  a  vain  attempt  to 
clear  the  intestinal  tract,  which,  from 
muscular  exhaustion  and  the  in- 
creased pressure  from  within,  due  to 
the  accumulation  of  intestinal  con- 
tents, finally  gives  rise  to  paresis, 
and  the  textural  changes  that  ac- 
company great  congestion  in  relaxed 
and  exhausted  tissues.  The  most 
prominent  clinical  evidences  of  the 
existence  of  acute  intestinal  obstruc- 
tion consist  in:  Absolute  constipation, 

vomiting,  interinittcnt,  colicky  pains,  and  tympanites.  If  the  obstruc- 
tion is  complete,  as  is  usually  the  ca.se  except  in  the  milder  forms 
of  invagination,  the  inte.stinal  contents  become  arrested  at  once  and 
completely  above  the  .seat  of  the  obstruction,  and  the  fecal  dis 
charges  .secured   after  the  accident   has   occurred,  by   the 


F'g-  475- — Resected  intestine. 
Thrombosis  of  mesenteric  vein  (Elliot' s 
case). 


of 


740  INTESTINAL    OBSTRUCTION. 

enemata  or  otherwise,  represent  only  the  contents  of  the  bowel 
below  the  obstruction.  The  last  normal  movement  of  the  bowels 
furnishes  some  indication  as  to  the  time  when  the  obstruction 
occurred.  In  the  milder  forms  of  invagination  hquid  feces  may 
pass  through  the  narrowed  lumen  of  the  intussusceptum,  and,  con- 
sequently, the  obstruction,  for  some  time  at  least,  may  not  be  com- 
plete, but  usually  becomes  so  later  by  dynamic  causes  above  the 
invagination. 

Vomiting  is  present  in  all  cases,  and  appears  early  and  proves 
most  persistent  the  nearer  the  obstruction  is  located  to  the 
stomach — that  is,  vomiting  appears  soon  and  at  short  intervals  if 
the  obstruction  affects  the  upper  portions  of  the  intestinal  canal, 
while  it  is  usually  delayed  for  some  time  and  occurs  at  irregular 
intervals  if  the  obstruction  is  located  near  or  below  the  ileocecal 
valve.  Attacks  of  vomiting  are  most  likely  to  occur  soon  after  the 
paroxysmal  attacks  of  pain.  The  character  of  the  material  ejected 
is  of  considerable  diagnostic  value.  Sooner  or  later  the  vomiting 
becomes  fecal,  and  the  lower  down  in  the  intestinal  tract  the 
obstruction  is  located,  the  more  marked  are  the  fecal  appearance  and 
odor  of  the  vomited  material. 

Colicky  Pains. — The  pain  that  attends  intestinal  obstruction  is 
intermittent,  and  is  produced  by  and  corresponds  in  time  with  the 
violent  peristalsis.  The  location  of  the  pain  is  little  or  no  indication 
of  the  seat  of  obstruction — at  first  it  is  usually  referred  to  the 
umbilical  region,  regardless  of  the  nature  or  seat  of  the  obstruction. 
The  strong  peristalsis  takes  place  in  the  small  intestine  area,  and 
the  character  of  the  pain,  as  well  as  its  location,  rather  indicate  the 
situation  of  the  intestines  above  the  obstruction  than  the  location  of 
the  obstruction  itself  Between  the  paroxysms  of  pain  a  sense 
of  relief  is  experienced  and  continues  until  the  next  attack  sets  in. 
Pressure  does  not  aggravate  the  pain  ;  on  the  contrary,  firm  diffuse 
pressure  relieves  it.  Tenderness  is  seldom  a  marked  symptom 
during  the  intervals. 

Tympanites  is  a  sign  common  to  peritonitis  and  intestinal  obstruc- 
tion. In  the  former  affection  it  appears  in  consequence  of  muscular 
paralysis  of  the  intestinal  wall,  resulting  from  the  inflammation;  in 
the  latter  it  is  the  final  outcome  of  the  mechanical  distention  caused 
by  the  accumulation  of  the  intestinal  contents  above  the  seat  of  the 
obstruction.  The  intestine  above  the  obstruction  is  ahvays  found 
extremely  vascular,  distended,  and  fragile  ;  below  the  obstruction,  pale, 
contracted,  and  firm.  In  intestinal  obstruction  the  tympanites  is 
caused  exclusively  by  distention  of  that  part  of  the  intestinal  canal 
above  the  obstruction. 

Kader  has  studied,  by  numerous  experiments  upon  animals,  the 
causes  and  varieties  of  distention  of  the  bowel  noticed  in  intestinal 
obstruction,  and  has  come  to  the  following  conclusions  : 

The  distention  is  due  to  interference  with  the  circulation  of  the 
wall  of  the  intestine  or  to  obstruction  by,  and  decomposition  of,  the 


TYMPANITES.  74! 

contents  of  the  intestinal  canal  above  the  obstruction.  In  the  first 
case  the  bowel-wall  becomes  thickened,  infiltrated  with  blood,  par- 
alyzed, and  finally  gangrenous,  while  the  intestine  is  filled  with 
bloody  serum  and  gas,  distending  it  to  two  or  three  times  its  orig- 
inal diameter.  In  the  second  class  the  bowel-wall  is  not  much 
altered,  excepting  some  paralysis  coming  on  after  several  days* 
duration  of  the  obstruction,  and,  in  chronic  cases,  the  compensatory 
hypertrophy  of  the  muscular  coat,  while  the  distention  is  less 
marked.  Peritonitis,  however,  will  cause  the  first-described  changes 
to  occur  even  when  the  circulation  of  the  bowel  is  not  directly 
involved.  If,  therefore,  the  circulation  of  a  loop  of  bowel  is  affected 
by  the  same  cause  that  obstructs  its  lumen,  we  shall  have  a  localized 
distention  and  threatening  gangrene  of  the  wall,  which  will  occur  so 
early  that  it  can  often  be  recognized  before  general  distention  is 
present.  Tympanites  is  slight  or  absent  if  the  obstruction  is  high 
up  in  the  intestinal  canal  ;  marked  if  it  affects  the  intestinal  tract  at 
or  below  the  ileocecal  region.  Owing  to  imperfect  occlusion  of 
the  lumen  of  the  bowel,  it  is  often  moderate  or  slight  in  many  cases 
of  invagination  as  compared  with  other  forms  of  obstruction  in  the 
same  locality.  Intestinal  distention  and  tympanites  of  the  free 
peritoneal  cavity  can  be  distinguished  by  the  relation  of  the  liver 
dullness  to  the  tympanitic  area.  In  the  former  case  the  liver  dull- 
ness is  displaced  in  an  upward  direction  ;  in  the  latter  event  it  dis- 
appears, unless  the  organ  has  become  previously  immobilized  by 
adhesions  or  by  the  presence  of  gas  between  the  surface  of  the  liver 
and  the  chest-w^all. 

The  symptoms  that  have  just  been  described  are  those  most 
relied  upon  in  differentiating  between  intestinal  obstruction  and 
peritonitis,  a  disease  that  it  often  simulates  very  closely.  There  are 
other  symptoms  that  must  be  taken  into  careful  consideration  in 
excluding  the  latter  disease. 

The  pulse  in  intestinal  obstruction  is  at  first  slow  and  full, 
becoming  small  and  frequent  as  prostration  and  septic  intoxication 
set  in,  while  in  peritonitis  the  pulse  is  rapid,  small,  and  wiry 
almost  from  the  beginning  of  the  attack.  The  temperature 
remains  normal  or  nearly  so  in  the  absence  of  complication,  while 
in  peritonitis  it  is  increased  ;  or,  in  the  gravest  cases,  subnormal, 
with  the  appearance  of  the  other  early  symptoms.  Rigidity  of  (he 
abdominal  muscles  indicates  peritonitis,  and  is  never  a  prominent 
symptom  in  intestinal  obstruction  uncomplicated  by  peritonitis.  Li  m  i  ted 
ascites  .speaks  in  favor  of  intestinal  obstruction  and  against  acute  peri- 
tonitis, as  has  been  shown  by  Gangolphc  and  Carl  Bayer.  The 
former  surgeon,  as  early  as  1893,  directed  attention  to  what  he  con- 
sidered as  a  new  sign,  by  means  of  which  he  thought  internal 
.strangulation  might  be  distinguished  from  other  forms  of  intestinal 
obstruction.  Bayer  has  called  especial  attention  to  limited  ascites 
as  an  imjjortant  sign  in  di.stinguishing  between  strangulation  of  the 
intestine  and  peritonitis.      Gangolphe  encountered  a  case  of  obstruc- 


742  INTESTINAL    OBSTRUCTION. 

tion  of  uncertain  diagnosis  ;  laparotomy  gave  escape  to  a  consider- 
able quantity  of  serosanguinolent  fluid,  similar  to  that  found  in  the 
sac  of  an  ordinary  strangulated  hernia.  On  exploration  of  the 
abdominal  cavity  the  cause  of  obstruction  was  discovered  in  an 
internal  strangulation  of  the  small  intestine  in  the  foramen  of  Win- 
slow.  It  occurred  to  him  that  the  presence  of  such  a  fluid  might 
be  characteristic  of  internal  strangulation,  and  so  enable  the  sur- 
geon to  distinguish  obstructions  of  this  kind  from  those  due  to  other 
causes.  Experiments  made  on  dogs  have  since  confirmed  this  view 
by  showing  that  constriction  of  a  loop  of  intestine  by  an  elastic 
ring  results  in  an  effusion  of  bloody  serum,  both  into  the  peritoneal 
cavity  and  the  intestine.  Moreover,  the  quantity  of  the  transuda- 
tion is  in  proportion  to  the  extent  of  strangulated  intestine  and  to 
the  intensity  of  the  constriction.  This  sign  is  likely  to  be  of  espe- 
cial value  in  cases  of  intestinal  obstruction  in  the  female,  as  the 
presence  of  ascites  in  the  abdominal  cavity  may  readily  be  deter- 
mined by  vaginal  examination  even  where  the  amount  of  the  effusion 
is  limited. 

In  making  a  probable  differential  diagnosis  between  intestinal  ob- 
struction and  peritonitis,  it  is  also  important  to  remember  the 
location  and  character  of  the  pain.  In  obstruction,  as  has 
been  stated,  the  pain  is  intermittent  and  almost  always  re- 
ferred, at  least  during  the  beginning  of  the  attack,  to  the 
umbilical  region  ;  on  the  other  hand,  in  peritonitis  it  is  con- 
stant, aggravated  during  increased  peristalsis,  but  never  entirely 
absent  except  in  cases  of  peritoneal  sepsis,  and  the  seat  of  pain 
corresponds  with  the  part  of  the  peritoneum  affected.  Exquisite 
tenderness  over  the  inflamed  peritoneum  is  a  constant  symptom 
in  peritonitis  ;  it  is  usually  absent  in  intestinal  obstruction.  Before 
coming  to  positive  diagnostic  conclusions,  it  is  extremely  important 
to  study  carefully  the  clinical  history,  and  to  analyze  carefully, 
collectively,  and  separately  the  existing  symptoms  and  the  order  in 
which  they  made  their  appearance.  The  most  difficult  cases,  from 
a  diagnostic  standpoint,  are  those  in  which  peritonitis  is  followed 
by  intestinal  obstruction,  or  intestinal  obstruction  by  peritonitis — that 
is,  the  coexistence  of  both  affections. 

As  in  strangulated  hernia,  the  symptoms  of  acute  intestinal 
obstruction  are  sometimes  masked,  and  their  intensity  does  not 
correspond  with  the  gravity  of  the  case.  Briggs,  of  Sacramento, 
has  related  a  very  instructive  case  of  this  kind.  The  case  was  one 
of  acute  obstruction  from  band  constriction,  and  terminated  in 
death  from  gangrene.  The  symptoms  were  so  mild  that  three 
days  after  the  supervention  of  complete  obstruction  and  two  days' 
vomiting,  the  patient  traveled  thirty- five  miles,  and  the  following 
day  walked  two  miles.  The  operation,  performed  on  the  fourth  day 
after  the  manifestation  of  the  first  symptoms,  showed  the  cause  of 
obstruction  to  be  a  band  of  constriction  under  which  the  bowel 
had  been  caught  in  such  a  manner  that  two  sections,  eight  and  six 


CHRONIC    INTESTINAL    OBSTRUCTION.  743 

inches  in  length,  had  become  gangrenous,  and  between  these  a 
portion  of  intestine  three  inches  in  length  had  remained  in  a  good 
condition.  Resection  and  circular  enterorrhaphy  were  performed, 
but  the  patient  died  two  and  a  half  hours  after  the  operation.  If, 
in  this  case,  the  operation  had  been  done  early, — that  is,  before 
gangrene  occurred, — it  would  have  been  a  comparatively  easy  matter, 
and  the  patient  would,  in  all  probability,  have  recovered,  as  the 
obstruction  could  have  been  removed  readily  and  permanently  by 
simple  division  or  excision  of  the  constricting  band. 

In  contrast  with  tiiis  case  we  find  occasionally,  during  operations 
for  intestinal  obstruction  attended  by  stormy  symptoms,  pathologic 
conditions  that  do  not  account  for  the  severity  of  the  symptoms. 
If  the  tympanites  is  not  extensive,  very  important  diagnostic  infor- 
mation can  often  be  obtained  by  resorting  to  rectal  insufflation  of 
air  to  the  extent  of  ballooning  of  the  bowel  below  the  obstruction, 
indicating,  approximately  at  least,  the  probable  anatomic  location  of 
the  obstruction.  Even  the  most  expert  surgeons,  after  resorting  to 
all  known  diagnostic  resources,  not  infrequently  fail  in  making 
a  correct  ante-operation  diagnosis.  Obalinski  proposed  abdominal 
section  in  thirty-eight  cases  of  intestinal  obstruction  from  almost 
every  possible  cause.  In  about  50  per  cent,  the  diagnosis,  both  as 
to  location  and  character  of  the  obstruction,  was  proved  to  be 
accurate.  He  is  of  the  opinion,  in  which  every  surgeon  fully  coin- 
cides, that,  even  by  a  resort  to  all  the  modern  diagnostic  aids,  an 
accurate  diagnosis  is  possible  only  in  about  one-third  of  the  total 
number  of  cases.  In  the  remaining  number,  when  symptoms  point 
to  obstruction,  but,  with  our  present  means  of  diagnosis,  we  are 
unable  to  make  a  positive  diagnosis,  he  is  in  favor  of  an  early 
exploratory  incision  through  the  median  line — an  opinion  sanc- 
tioned by  most  of  the  surgeons  at  the  present  time. 

Chronic  Intestinal  Obstruction. — In  chronic  intestinal  ob- 
struction the  mechanical  impediment  to  the  passage  of  feces  is 
progressive — that  is,  the  constriction  or  compression  of  the  bowel 
is  due  to  causes  that  gradually  diminish  the  lumen  of  the  bowel. 
The  intrinsic  causes  of  this  clinical  form  of  obstruction  are 
usually  cicatricial  stenosis,  malignant  tumors,  and  the  extrinsic 
inflammatory  exudates  or  tumors,  both  malignant  and  benign. 

The  symptoms  usually  develop  very  slowly  as  the  occlusion 
becomes  more  complete.  In  other  cases  the  chronic  process  wliich 
results  in  ob.struction  does  not  give  rise  to  any,  or  but  slight, 
symptoms  until  acute  symptoms  announce  the  presence  of  an 
obstruction.  During  the  early  part  of  the  affection  the  bowel 
above  the  .scat  of  ob.struction  undergoes  compensatory  hyper- 
trophy, dilatation  taking  place  very  slowly  unless  tiic  chronic  sud 
denly  merges  into  the  acute  form — an  event  that  is  always  an- 
nounced by  a  complexus  of  symptoms  characteristic  of  acute  or 
subacute  obstruction.  Chronic  ob.struction  is  more  frequently  met 
in  persons  advanced  in  years,  and  the  scat  of  obstruction  is  usually 


744  INTESTINAL    OBSTRUCTION. 

located  in  some  part  of  the  large  intestine.  One  of  the  earliest 
indications  of  the  existence  of  a  chronic  obstruction  is  diarrhea,  caused 
by  a  catarrhal  inflammation  of  the  mucous  membrane  above  the  ob- 
struction. It  is  in  cases  of  this  kind  that  a  careful  inquiry  into  the 
clinical  history  will  usually  reveal  the  fact  that  irregularity  of  the 
bowels — diarrhea  alternated  by  constipation — was  present  a  long 
time  before  the  patient  sought  medical  advice.  Repeated  and  well- 
directed  questions  will  frequently  result  in  a  statement  by  the 
patient  to  the  effect  that  the  stools,  when  solid,  have  for  some  time 
been  smaller  in  caliber  than  normal,  or  flattened.  Besides  diarrhea, 
usually  alternated  by  constipation,  the  most  prominent  clinical 
features  of  chronic  intestinal  obstruction  are  attacks  of  colicky 
pains,  gradually  increasing  tympanites,  and  visible  intestinal  coils 
during  the  paroxysmal  pains.  The  colicky  pains  have  the  same 
meaning  as  in  acute  obstruction — exaggerated  intestinal  peristalsis, 
vain  attempts  to  overcome  the  gradually  increasing  mechanical 
obstruction.  The  tympanites  during  the  early  stages  of  chronic 
intestinal  obstruction  is  often  temporary,  always  attended  by 
paroxysmal  pains,  and  relieved  by  the  free  passage  of  gas  and 
liquid  intestinal  contents.  The  attacks  of  pain  and  tympanites 
usually  come  on  at  irregular  intervals,  and,  as  a  rule,  increase  in 
intensity  with  each  successive  attack. 

One  of  the  most  important  signs  of  intestinal  obstruction,  both 
acute  and  chronic,  so  long  as  the  imiscidar  coat  of  the  intestine 
remains  active,  is  the  appeara7ice  of  intestinal  coils  in  the  small 
intestine  area  during  the  stormy  attacks  of  exaggerated  iittestinal 
peristalsis.  In  obese  persons  this  sign  is  absent,  owing  to  the 
thickness  of  the  abdominal  wall.  Whenever  this  sign  makes  its 
appearance,  it  precludes  peritonitis,  and  is  an  almost  infallible  indi- 
cation of  the  existence  of  some  kind  of  intestinal  obstruction.  In 
infants  and  young  children  chronic  intestinal  obstruction  usually  in- 
dicates chronic  invagination  ;  in  young  adidts,  cicatricial  stenosis  or 
compression  of  the  intestine  by  a  tumor  ;  in  persons  advanced  in  years, 
malignant  disease. 

Medical  Treatment. — With  very  few  exceptions,  indeed,  mechan- 
ical obstruction  of  the  intestines  is  amenable  to  successful  treatment 
only  by  early  operative  interference.  In  such  cases  medical  treat- 
ment is  unavailing,  and  the  time  lost  in  experimenting  with  it  adds 
to  the  gravity  of  the  case  and  increases  the  difficulties  to  a  success- 
ful subsequent  operation.  Medical  treatment  offers  some  encour- 
agement in  cases  of  intestinal  obstruction  due  to  dynamic  causes. 
According  to  the  statistics  of  Curschmann,  Goltdammer,  and  Biilau, 
about  one-third  of  the  cases  of  intestinal  obstruction  met  in  general 
practice  can  be  saved  by  well-planned  internal  medication,  and  we 
have  reason  to  assume  that  most  of  these  cases  are  due  to  dynamic 
obstruction  ;  consequently  two-thirds  of  all  the  cases  belong  from 
the  very  beginning  to  the  surgeon,  and  must  be  subjected,  at  the 
earliest  possible  moment,  to  direct  treatment  of  the  mechanical  con- 


MEDICAL    TREATMENT. 


745 


ditions  that  cause  the  obstruction.  It  is  in  doubtful  cases,  in 
which  it  is  difficult  or  impossible  to  differentiate  between  obstruction 
due  to  mechanical  and  obstruction  due  to  dynamic  causes  that 
medical  treatment  desei-ves  a  tentative  trial,  but  always  in  con- 
sonance with  the  significant  motto,  nil  nocere.  In  dynamic  obstruc- 
tion more  persistent  efforts  are  not  infrequently  crowned  by  success. 

Sev^eral  things  must  never  be  neglected  in  all  cases  of  intestinal 
obstruction,  regardless  of  its  cause:  (i)  Suspension  of  stomach- 
feeding  ;  (2)  efforts  to  move  the  bowels  by  copious  enemata;  (3) 
lavage  of  the  stomach. 

Attempts  at  stomach-feeding  always  aggravate  the  intestinal 
peristalsis,  and  consequently  provoke  retching  and  vomiting,  condi- 
tions that  can  not  fail  in  exerting  a  harmful  influence  upon  the 
cause  of  obstruction,  whether  this  be  of  a  mechanical  or  dynamic 
nature.  Stomach  rest  cojistitiites  an  important  element  in  modifying 
favorably  the  intestinal  unrest  by  limiting  the  intestinal  contents. 
Food  and  water  in  sufficient  quantities  must  be  supplied  by  rectal 
enemata  after  the  large  intestine  has  been  thoroughly  cleared  out 
by  a  copious  enema.  If  this  method  of  alimentation  has  to  be 
continued  for  a  long  time  and  the  rectum  has  become  irritable,  the 
nutrient  enemata  should  be  administered  through  the  elastic  rectal 
tube,  so  as  to  utilize  the  colon  as  an  absorbing  surface.  Pepto- 
nized milk  and  beef  and  albumin  of  q^^  in  normal  salt  solution  are 
the  best  preparations  for  rectal  alimentation.  The  system  is  to  be 
supplied  with  the  requisite  amount  of  water,  which  can  be  done 
most  speedily  and  satisfactorily  by  using  the  normal  salt  solution  in 
place  of  plain  w^ater,  as  it  is  absorbed  much  more  quickly  and 
causes  less  irritation. 

Evacuation  of  the  colon  by  copious  rectal  injections  is  resorted 
to  almost  instinctively  in  every  case  of  intestinal  obstruction.  This 
procedure  is  of  therapeutic  value  by  emptying  the  bowel  of  its  con- 
tents and  in  increasing  peristaltic  action  below  the  obstruction.  The 
capacity  of  the  large  intestine  in  adults  is  at  least  four  quarts,  and 
this  is  the  amount  that  should  be  administered.  Soapsuds,  with 
the  addition  of  a  tablespoonful  of  common  salt  and  four  table- 
spoonfuls  of  castor  oil,  is  a  very  common  and  useful  combination 
for  a  simple  laxative  enema.  Some  prefer  glycerin  to  oil;  others 
use  a  solution  of  sulphate  of  soda  or  magnesia.  A  fountain  syringe 
holding  a  gallon  of  fluid  is  the  best  apparatus  for  administering  the 
enema.  If  the  rectum  is  very  irritable,  it  is  necessary  to  press  the 
margins  of  the  anus  closely  against  the  rectal  tip  until  the  desired 
amount  of  fluid  has  been  administered.  The  knce-clicst  or  elbow 
position  will  materially  facihtate  the  administration  of  a  copious 
enema.  If,  for  any  reason,  this  position  can  not  be  employed,  the 
patient  should  be  placed  with  the  pelvis  elevated  on  the  right  side, 
and  kept  in  this  positifjn  until  the  injection  is  expelled  by  the  vio- 
lent peristalsis  which  the  injection  provokes. 

Lavage  of  the  stomach  is  a  very  important  therapeutic  resource 


746 


INTESTINAL    OBSTRUCTION. 


in  all  cases  of  intestinal  obstruction.  The  accumulation  of  intes- 
tinal contents  above  the  seat  of  obstruction  acts  deleteriously  in 
several  ways  : 

1.  It  causes  violent  peristaltic  action  of  the  intestine  above  the 
seat  of  obstruction. 

2.  It  exhausts  the  patient's  strength  by  causing  persistent  retch- 
ing and  vomiting. 

3.  It  is  one  of  the  causes  that  produce  distention   of  the  in- 
testine. 

4.  It  favors  fermentative  and  putrefactive  changes  in  the  intes- 
tine by  the  fluid  serving  the  purpose  of  a  nutrient  medium  for 
pathogenic  micro-organisms.  In  my  experiments  on  animals,  where 
I  made  complete  obstruction  I  never  witnessed  such  persistent 
vomiting  as  in  man.  I  attributed  this  difference  to  the  fact  that 
animals  thus  treated  refuse,  as  a  rule,  both  food  and  drink,  and  that 
the  intestinal  canal,  in  proportion  to  the  size  of  the  abdominal  cavity, 
is  much  shorter  than  in  man.  Patients  suffering  from  acute  intes- 
tinal obstruction  should  abstain 
from  taking  either  food  or  drink, 
as  digestion  and  absorption  are 
almost,  if  not  completely,  sus- 
pended, and  the  accumulation 
of  fluids  can  not  fail  in  aggra- 
vating the  symptoms. 

Kussmaul  has  introduced  a 
new  and  exceedingly  valuable 
therapeutic  measure  in  the  treat- 
ment of  intestinal  obstruction  in 
the  use  of  the  elastic  stomach- 
tube.  By  the  siphon  action  of 
the  tube,  gas  and  fluid  contents 
upper  portion  of  the  intestinal  canal  are 
abdominal    distention    is    relieved    and    the 


Fig.  476. — Soft-rubber  stomach-tube  with 
funnel  and  exhaust  bulb. 


of  the  Stomach  and 
evacuated,  and  thus 
hydrostatic  pressure  in  the  intestine  above  the  obstruction  dimin- 
ished. He  claims  for  this  measure  the  following  advantages : 
(i)  Intra-abdominal  tension  is  diminished,  and  thus  the  first  condi- 
tion secured  for  the  correction  of  the  mechanical  difficulties  that 
have  caused  the  obstruction.  (2)  It  relieves  the  distention  of  the 
bowel  above  the  seat  of  obstruction,  and  consequently  also  the 
pressure  of  the  intestines  against  each  other,  a  condition  that  can 
not  fail  to  impair  peristaltic  action.  (3)  Finally,  what  is  most  im- 
portant, by  evacuating  the  accumulated  contents  it  diminishes  the 
violent  peristalsis.  He  reports  the  case  of  an  adult  where  an  intes- 
tinal obstruction,  due  to  an  invagination,  had  lasted  twenty-three 
days,  and  that  yielded  to  daily  irrigations  of  the  stomach.  A  por- 
tion of  the  intussusceptum  sloughed  and  was  found  in  the  stool. 
The  patient  died  later  of  peritonitis,  which  may  have  started  from 
the  seat  of  invagination. 


IRRIGATION    OF    THE    STOMACH,  747 

Bardeleben,  in  a  paper  on  the  treatment  of  acute  intestinal  ob- 
struction, praises  the  utiHty  of  irrigation  of  the  stomach  as  a  palha- 
tive  means,  but  speaks  at  the  same  time  of  the  danger  incident  to 
the  employment  of  such  a  temporizing  measure,  as  too  much  valua- 
ble time  may  be  lost  before  a  curative  treatment  is  adopted.  He 
reports  a  case  in  which  irrigation  afforded  such  absolute  relief  that 
the  operation  was  postponed  until  it  could  no  longer  be  of  any 
avail.  Kuester  expects  from  irrigation  of  the  stomach  prompt 
palliative  effects,  but  warns  not  to  persist  with  it  in  cases  where  the 
seat  and  cause  of  the  obstruction  can  be  ascertained.  Hahn  looks 
upon  it  as  a  curative  agent  only  in  cases  where  the  obstruction  is 
due  to  coprostasis  in  the  large  intestine,  and  he  claims  that  in  such 
cases  irrigation  of  the  colon  would  lead  more  promptly  to  the 
desired  result. 

Schlegtendal  claims  that  lavage  of  the  stomach  in  the  treatment 
of  intestinal  obstruction  fulfils  a  threefold  therapeutic  indication  : 
(i)  It  prevents  distressing  symptoms  ;  (2)  it  alleviates  them  when 
they  are  present  ;  (3)  in  some  cases  it  cures  the  disease. 

Rehn  maintains  that  irrigation  of  the  stomach,  as  devised  by 
Kussmaul,  in  the  treatment  of  intestinal  obstruction  not  only 
empties  the  stomach  of  its  contents,  but  also  evacuates  a  certain 
portion  of  the  intestinal  canal  above  the  seat  of  obstruction.  In 
two  cases  of  intestinal  obstruction  where  this  expedient  was  resorted 
to  after  the  abdominal  cavity  was  opened  he  observed  that  a  con- 
siderable portion  of  the  dilated  intestine  was  emptied  of  its  con- 
tents. 

Heusner  states  that  by  this  means  many  liters  of  intestinal  con- 
tents can  be  removed,  pain  is  relieved,  eructation  and  vomiting  are 
controlled,  peristalsis  is  quieted,  the  function  of  the  stomach  is 
restored,  and  suitable  nourishment  can  be  taken  and  assimilated, 
thus  maintaining  strength  and  life  until  the  cause  of  obstruction  is 
removed  spontaneously  or  through  the  intervention  of  surgery. 
Madelung  has  called  attention  to  the  necessity  of  resorting  to  irri- 
gation of  the  stomach  prior  to  the  administration  of  an  anesthetic  in 
operations  for  intestinal  obstruction,  as  without  such  precaution 
there  is  danger,  during  the  attacks  of  vomiting  that  are  almost  sure 
to  be  provoked  by  the  anesthetic,  of  fluid  entering  the  trachea, 
causing  suffocation  or,  later,  pneumonia. 

As  an  aid  in  the  treatment  of  intestinal  obstruction  due  to 
mechanical  causes,  irrigation  of  the  stomach  should  always  be  sys- 
tematically practised  every  four  to  six  hours,  but  as  a  curative 
measure  it  should  never  be  relied  upon.  I  have  always  combined 
emptying  of  the  stomach  with  irrigation,  using  large  quantities  of 
warm  water  rendered  antiseptic  by  the  addition  of  salicylated  soda 
or  hypophosphite  of  soda.  The  washing  out  of  the  stomach  with 
a  harmless  and  efficient  anti.scptic  .solution  has  a  decided  beneficial 
effect  in  preventing  fermentative  and  putrefactive  changes  in  the 
intestinal  contents  above  the  seat  of  obstruction. 


748  INTESTINAL    OBSTRUCTION. 

The  use  of  cathartics,  as  a  rule,  can  not  be  condemned  too 
strongly.  They  may  prove  useful  in  isolated  cases  of  dynamic 
obstruction  in  which  the  muscular  coat  of  the  affected  intestine  is 
in  a  condition  able  to  respond  to  the  stimulation  of  the  cathartic, 
but  such  cases  are  rare,  and  it  requires  great  diagnostic  skill  to 
make  a  safe  selection  of  cases.  If  it  is  deemed  advisable  to  resort 
to  cathartics,  calomel  and  the  saline  preparations  deserve  the  pref- 
erence. Twelve  grains  of  calomel  and  half  a  dram  of  bicarbonate  of 
soda  rubbed  together  with  a  little  sugar  and  divided  into  twelve 
powders  is  a  prescription  that  deserves  consideration.  The  powders 
should  be  given  at  intervals  of  half  an  hour  or  an  hour,  and  if  the 
desired  result  is  not  realized,  a  saline  cathartic  will  be  in  place.  A 
teaspoonful  of  sulphate  of  magnesia  in  saturated  solution  every  hour 
or  two  will  act  promptly  if  such  a  result  is  compatible  with  the 
nature  of  the  obstruction.  Not  more  than  eight  doses  should  be 
used.  Seidlitz  powders  and  effervescing  citrate  and  sulphate  of 
magnesia  are  excellent  preparations  in  such  cases.  Opium  has  a 
place  in  the  treatment  of  acute  intestinal  obstruction,  as  it  eases 
pain,  quiets  the  stormy  peristalsis,  and  contributes  much  toward 
securing  rest  for  the  intestines  and  toward  preparing  the  patient 
properly  for  the  operation.  It  is  always  contraindicated  in  chronic 
obstruction,  as  in  these  cases  operative  treatment  is  always  indicated 
as  soon  as  a  diagnosis  can  be  made. 

In  all  cases  of  intestinal  obstruction,  but  more  particularly  in 
the  chronic  form,  uniform  firm  support  of  the  abdomen  affords 
relief  to  the  patient,  and  is  one  of  the  best  means  of  preventing 
rapid  distention  of  the  intestine  above  the  seat  of  obstruction.  Fix- 
ation and  equable  compression  are  resorted  to  in  other  parts  of  the 
body  as  the  best  known  means  for  controlling  muscular  spasm.  It 
is  only  reasonable  to  expect  that  the  same  measures  should  prove 
useful  in  retarding,  if  not  preventing,  the  violent  peristalsis  in  cases 
of  intestinal  obstruction,  and  especially  in  preventing  overdistention 
of  the  intestine.  Equable  compression  of  the  abdomen  should  be 
made  before  great  distention  has  occurred.  Uniform  compression 
of  the  abdomen  is  best  secured  by  padding  the  iliac  regions  with 
absorbent  cotton  and  then  enveloping  the  body  from  the  pubes  to 
the  tip  of  the  sternum  with  broad  strips  of  adhesive  plaster,  which 
should  be  made  to  overlap  each  other. 

Distention  of  the  colon  with  fluids  will  often  prove  useful  as  a 
diagnostic  as  well  as  a  therapeutic  aid,  more  especially  in  cases  of 
invagination.  This  procedure  has  been  ernployed  with  the  inten- 
tion of  utilizing  the  hydrostatic  pressure  as  a  means  of  correct- 
ing the  mechanical  difficulties  that  have  given  rise  to  the 
obstruction.  This  method  of  treatment  and  diagnosis  brings  up 
the  much-disputed  subject  concerning  the  permeability  of  the 
ileocecal  region  to  rectal  injections  of  fluids  and  air  or  gases. 
The  majority  of  those  who  have  studied  the  subject,  clinically 
or  by  experiment,  make  the  positive   assertion  that  the  ileocecal 


DISTENTION    OF    THE    COLON    WITH    FLUIDS.  749 

valve  is  perfectly  competent,  and  effectually  guards  the  ileum 
against  the  entrance  of  both  fluids  and  gases  forced  into  the 
rectum ;  others  insist  that  it  is  permeable  only  in  exceptional 
cases  ;  and  but  a  few  claim  that  its  resistance  can  be  overcome 
by  a  moderately  safe  degree  of  pressure. 

Heschl  made  a  number  of  experiments  on  the  cadaver,  and 
satisfied  himself  that  the  ileocecal  valve  serves  as  a  safe  and  perfect 
barrier  against  the  entrance  of  fluids  from  below.  In  testing  the 
resisting  power  of  the  coats  of  the  intestine,  he  found  that  the 
serous  coat  of  the  colon  gave  way  first  to  overdistention,  while  the 
remaining  tissues  yielded  subsequently  to  a  somewhat  slighter 
pressure. 

Ball  has  found  that  in  the  adult  one  quart  of  water  injected  by 
the  rectum  will  reach  the  cecum,  but  that  the  entire  capacity 
of  the  large  intestine  is  from  four  to  five  quarts.  He  is  of  the 
opinion  that  in  the  living  body  fluid  can  not  be  forced  beyond  the 
ileocecal  valve,  although  ancient  and  modern  experimenters  claim 
to  have  succeeded  in  doing  so  in  the  cadaver.  He  affirms  that 
when  the  rectum  and  colon  are  distended  by  air,  the  ileocecal  valve 
is  rendered  incompetent  and  the  air  passes  into  the  small  intestine. 

Cantani  is  a  firm  believer  in  the  permeability  of  the  ileocecal 
valve  to  fluid  by  rectal  injections.  In  one  instance  he  treated  a 
case  of  coprostasis  by  an  injection  of  a  quart  and  a  half  of  oil  by 
the  rectum,  and  an  hour  later  a  part  of  the  oil  was  ejected  by 
vomiting.  He  advises  that  the  intestinal  tract  above  the  ileocecal 
valve  should  be  utilized  as  an  absorbing  surface  in  cases  requiring 
rectal  alimentation,  and  when  in  a  diseased  condition,  should  be 
treated  by  topical  applications. 

Behrens  concluded  from  his  experiments  that  it  required  the 
insufflation  by  the  rectum  of  more  than  a  quart  in  volume  of  air  to 
reach  the  ileum  through  the  ileocecal  valve.  In  his  experiments 
he  had  no  difficulty  in  overcoming  the  competency  of  the  ileocecal 
valve  by  rectal  insufflation  of  air. 

Debierre  made  numerous  experiments  on  the  cadaver  to  test 
the  permeability  of  the  ileocecal  valve  to  rectal  injections  of  fluids 
or  insufflation  of  air.  The  results  that  he  obtained  were  not  con- 
stant. In  some  subjects  the  valve  proved  permeable  only  to  air  ; 
in  others,  to  both  air  and  water,  while  in  some  no  air  or  fluids  could 
be  forced  into  the  ileum  by  any  degree  of  force.  When  the  intes- 
tine was  left  in  situ,  the  valve  was  found  less  permeable  than 
when  it  had  been  removed  from  the  body.  He  attributes  the  differ- 
ent degrees  of  competency  of  the  valve  to  variations  in  the  anatomic 
construction  of  the  valve.  If  both  lips  of  the  valve  arc  equal  in 
length,  or  if  the  lower  lip  is  longer,  the  valve  was  found  imperme- 
able. It  i)rovcd  permeable  in  ca.ses  where  the  lower  lip  was  siiorter, 
contracted,  and  smaller  than  the  upi)er.  In  tiie  last  instance  the 
advancing  volume  of  fluid  or  air  lifted  the  upper  valve,  while  in  the 
former  structure  of  the   valve  the   margins   of  the  lips  of  the  valve 


750  INTESTINAL    OBSTRUCTION. 

were  approximated,  perfectly  shutting  off  all  communication  between 
the  colon  and  the  ileum. 

Mr.  Lucas  enumerates  the  following  objections  against  forcible 
rectal  injections  of  water  as  a  means  of  reducing  an  invagination  : 

1.  Owing  to  its  weight,  it  exerts  much  too  strong  lateral  pres- 
sure for  the  intestine  safely  to  bear,  and  he  has  found  it  easy  to 
rupture  the  bowel  after  death  by  forcing  in  water. 

2.  Should  reduction  have  been  accomplished,  the  contact  of  a 
large  quantity  of  water  with  the  large  bowel  is  apt  to  increase  the 
tendency  to  diarrhea.  He  claims,  very  properly,  that  gas,  on  the 
other  hand,  is  a  natural  occupant  of  the  intestinal  canal,  and,  while 
its  pressure  is  of  the  gentlest,  its  presence  excites  no  unnatural 
peristaltic  action.  He  administers  an  anesthetic  to  the  point  of 
relaxation  before  the  inflation  is  attempted. 

Dawson  made  a  number  of  experiments  on  the  cadaver,  and 
came  to  the  conclusion  that  when  the  ileocecal  valve  is  in  a 
normal  condition,  it  effectually  guards  the  small  intestine  against 
the  ingress  of   fluids  from  below. 

Illoway  devised  a  force  pump  that  he  strongly  recommends 
for  the  purpose  of  forcing  water  beyond  the  ileocecal  valve  in 
case  the  obstruction  is  located  above  that  point.  He  reports 
four  cases  treated  by  this  method,  three  of  which  recovered. 

Battey  believed  that  the  ileocecal  valve  is  permeable  to  the 
passage  of  fluids  forced  into  the  colon  if  the  patient  is  anesthe- 
tized. 

Insufflation  of  air  by  the  rectum  in  the  treatment  of  intestinal 
obstruction  has  been  known  since  the  time  of  Hippocrates.  Gor- 
ham  was  the  first  to  resort  to  this  method  of  treatment  in  England. 
In  comparing  the  effects  of  enemata  to  air  insufflation,  he  says  : 
"  But  the  effect  is  totally  different  when  air  is  used  ;  its  freedom 
from  all  irritating  qualities,  its  elasticity  and  expansibility,  give  it  a 
decided  preference  over  enemata." 

In  a  paper  read  before  the  Surgical  Section  of  the  Washington 
International  Medical  Congress,  I  detailed  the  results  of  a  large 
number  of  experiments  made  on  dogs  to  determine,  to  my  own 
satisfaction,  the  extent  to  which  the  ileocecal  valve  is  permeable  to 
fluids  forced  from  below.  In  three  cases  where  fluid  was  forced 
beyond  the  ileocecal  valve  the  postmortem  revealed  multiple  lacer- 
ations of  the  peritoneal  investment  of  the  large  intestine  in  two  of 
them,  while  the  third  animal  sickened  immediately  after  the  exper- 
iment was  performed,  and  died  eight  days  later  from  the  effects  of 
the  injury  inflicted. 

These  experiments,  combined  with  cHnical  experience,  leave 
no  further  doubt  that,  practically,  the  ileocecal  valve  is  impermeable 
to  fluids  from  below,  and  that  for  diagnostic  and  therapeutic  pur- 
poses it  is  unsafe  and  unjustifiable  to  attempt  to  force  fluids  beyond 
the  ileocecal  valve.  In  two  cases  of  ileocecal  invagination  in  children 
less  than  two  years  of  age   I   succeeded  in   reducing  the  bowel  by 


RECTAL    INSUFFLATION    OF    HYDROGEN    GAS    AND    AIR.  751 

Steady  hydrostatic  pressure  Vhile  the  httle  patients  were  under  the 
influence  of  an  anestiietic  and  held  in  the  inverted  position  In  both 
mstances  the  mvagination  had  existed  for  two  or  three  days  We 
should,  a  prion,  expect  that  air  and  gases,  on  account  of  their 
lesser  weight  and  greater  elasticity  than  water,  could  be  forced 
along  the  intestinal  canal  with  less  force,  and  for  that  reason  alone  if 
lor  no  other,  should  be  preferred  to  water  in  cases  where  it  appears 
desirable  to  distend  the  intestine  below  or  above  the  ileocecal  valve 
tor  diagnostic  or  therapeutic  purposes. 

Rectal  Insufflation  of  Hydrogen  Gas  and  Air.— Hydroc-en  eas 
IS  the  lightest  of  all  known  gases.      I  have  demonstrated" by  my 
experiments  that  this  gas  is  nontoxic,  nonirritant  when  injected  into 
the  connective  tissue  and  into  large  serous  cavities,  and  is  rapidly 
remoxed  by  absorption.      Distention  of  the  entire  gastro-intestinal 
canal  with  this  gas  by  rectal  insufflation,  both  in  man  and  animals 
was  never  followed  by  any  immediate  or  remote  ill  effects      Ac' 
curate  experiments  to  determine  the  force  requisite  to  render  the 
Ileocecal  vah-e  incompetent  by  insufflation  of  air  or  gas  had  previ- 
ously not  been  made,  and  as  it  is  exceedingly  important  to  obtain 
accurate  information  on  this  subject,  I  made  a  number  of  inflations 
in  animals  and  man,  estimating  at  the  same  time  the  pressure  under 
which  It  was  made,  with  either  a  mercury  gage  or  a  manometer 
such  as  is  used  by  gas-fitters  and  plumbers.      The  gas  was  collected 
in  a  four-gallon  rubber  balloon,  and  the  inflation  made  by  compres- 
sing the  balloon.    The  manometer  or  mercury  gage  was  connected  by 
meansof  rubber  tubing  with  tiie  rectal  tube  on  one  side  and  the  rubber 
balloon  on  the  other.      Numerous  experiments  showed  that  when  the 
gas  was  forced  through  the  opening  of  a  stop-cock,  the  lumen  of 
which  was  about  the  size  of  a  knitting-needle,  compression  equal  to 
200  pounds  (90  kilograms)  would  never  register  more  than  two  and 
one-half  to  three  pounds  of  pressure  to  the  square  inch.      In  the 
living  subject  the  escape  of  gas  from  the  rectum  was  prevented  by 
an  assistant  pressing  the  margins  of  the  anus  firmly  against  the 
rectal  tube.      A  number  of  experiments  made  for  the  special  pur- 
pose of  measuring  the  resisting  cai)acity  of  the  ileocecal  valve  to 
the  entrance  of  gas  from  the  cecum  into  the  ileum  showed  that  in 
a  normal  condition  the  valve  in  a  healthy  adult  person  is  overcome 
by  rectal  inflation  under  a  pre.ssure  varying  from  one  and  a  half  to 
two  and  one-fourth  pounds  (0.6  to  1.2  kilograms).     This  amount 
of  pressure  is  not  sufficient  to  injure  any  of  the  coats  of  a  healthy 
intestine  in  any  part  of  its  course.      As  the  result  of  numerous  ob- 
servations on  man  and  animals,  it  can  be  stated  that  when  the  infla- 
tion   is    made    slowly    and    continuously,   there    is  less  danger  of 
inflicting    injury    than   when   it    is    done    rapidly  or    interruptedly. 
When  the  patient  is  placed  fully  under  the  influence  of  an  anesthetic, 
the  ileocecal  valve  yields  to  a  lower  pressure  than  when  the  abdom- 
inal muscles  are  in  a  sLite  of  rigidity,  as  this  interferes  with  the  re- 
quLsite  degree  of  distention  of  tiie  cecum  which  is  necessary  to  effect 


752  INTESTINAL    OBSTRUCTION. 

the  separation  of  the  margins  of  the  valve.  A  rubber  balloon 
holding  four  gallons  (twenty  liters)  is  the  simplest,  safest,  and  most 
efficient  apparatus  for  making  rectal  insufflation  both  for  diagnostic 
and  curative  purposes. 

Another  series  of  experiments  on  dogs  was  made  for  the  pur- 
pose of  determining  the  degree  of  pressure  required  to  force  hy- 
drogen gas  from  anus  to  mouth — the  whole  length  of  the  gastro- 
intestinal canal.  In  all  the  experiments  the  pressure  fell  rapidly 
after  the  ileocecal  valve  had  been  opened,  but  it  had  again  to  be  in- 
creased before  the  gas  reached  the  stomach  and  escaped  through 
the  stomach-tube.  It  usually  required  one-half  to  one  pound  more 
pressure  to  force  gas  through  the  entire  length  of  the  alimentary 
canal  than  when  it  had  to  be  forced  through  only  the  ileocecal  valve. 
Whenever  it  becomes  necessary  to  conduct  the  hydrogen  gas  a 
considerable  distance  along  the  intestines  or  through  the  entire 
alimentary  canal,  it  is  exceedingly  important  to  proceed  slowly  with 
the  inflation,  as  under  slow  gradual  distention,  half  a  pound  (0.2 
kilogram)  of  pressure  to  the  square  inch  of  surface  will  accomplish 
in  time  a  great  deal  more  without  doing  harm  than  four  times  this 
amount  of  pressure  if  the  force  is  applied  quickly  and  only  for  a 
short  time.  In  the  dog,  rectal  insufflation  of  hydrogen  gas  made 
under  a  pressure  of  one-quarter  of  a  pound,  if  made  very  slowly 
and  uninterruptedly,  the  abdominal  walls  being  completely  relaxed 
by  an  anesthetic,  will  not  only  overcome  the  resistance  offered  by 
the  ileocecal  valve,  but  will  prove  sufficient  to  force  the  gas  through 
the  whole  length  of  the  alimentary  canal. 

Experiments  made  on  different  portions  of  the  gastro-intestinal 
canal  when  in  a  healthy  condition  and  removed  soon  after  death 
proved  that  laceration  did  not  take  place  under  a  pressure  of  less 
than  eight  pounds,  and  often  it  had  to  be  increased  to  twelve  pounds. 
It  was  found  that  the  resisting  power  of  the  intestinal  wall  is  nearly 
the  same  throughout  the  entire  length  of  the  canal,  and  in  a  nor- 
mal condition  yielded  to  a  diastaltic  force  of  from  eight  to  twelve 
pounds  of  pressure.  When  rupture  took  place,  it  occurred  either 
as  a  longitudinal  laceration  of  the  peritoneum  on  the  convex  sur- 
face of  the  bowel,  or  as  multiple  ruptures  from  within  outward  at 
the  mesenteric  attachment.  The  former  result  followed  rapid,  and 
the  latter  slow,  inflation.  The  superiority  of  hydrogen  gas  or  air 
inflation  over  injections  of  liquids  in  the  mechanical  treatment  of 
intestinal  obstruction  is  apparent.  Liquid  injections  can  not  safely 
be  forced  beyond  the  ileocecal  valve,  and  even  in  distending  the 
entire  colon  by  liquids  a  great  deal  more  force  is  required  than  by 
insufflation  with  hydrogen  gas  or  air.  Insufflation  of  hydrogen 
gas  or  air  is  a  valuable  means  of  diagnosis  in  locating  the  seat  of 
obstruction  before  tympanites  has  set  in,  and  therefore  best  adapted 
at  a  time  when  most  needed — during  the  early  stage  of  intestinal 
obstruction.  If  the  colon  dilates  uniformly  from  the  sigmoid  flex- 
ure to  the  cecum,  the  obstruction  must  be  sought  for  higher  up  in 


RECTAL    INSUFFLATION    OF    HYDROGEN    GAS    AND    AIR.  753 

the  intestinal  canal.  The  passage  of  gas  through  the  ileocecal 
valve,  rendered  incompetent  by  the  distention  of  the  cecum,  is 
always  attended  by  a  characteristic  gurgling  or  blowing  sound, 
which  is  always  heard  more  distinctly  by  applying  the  ear  or 
stethoscope  over  the  ileocecal  region.  Not  infrequentl}^  the  sounds 
are  so  loud  and  distinct  that  they  can  be  heard  at  a  distance  of  sev- 
eral feet.  If  the  gas  passes  the  ileocecal  valve  under  a  pressure  not 
in  excess  of  that  required  to  overcome  it  in  a  state  of  health,  and 
if,  after  inflation,  a  thorough  examination  of  the  ileocecal  region  by 
inspection,  palpation,  and  percussion  reveals  nothing  abnormal, 
the  search  for  the  obstruction  is  continued  by  inflating  the  small 
intestine  slowly  and  making  frequent  examinations  of  the  abdomen 
to  ascertain  the  height  to  which  inflation  has  been  made  and  to 
study  the  relative  position  of  the  different  abdominal  organs.  In- 
flation is  also  a  useful  diagnostic  resource  in  locating  the  obstruc- 
tion during  laparotomy  for  intestinal  obstruction.  The  intestine 
below  the  seat  of  obstruction  is  always  empty,  collapsed,  and 
anemic  as  compared  with  the  portion  above  the  obstruction.  When 
the  obstruction  is  located  high  up  in  the  intestinal  canal  and  the 
tympanites  is  extensive,  the  empty  portion  of  the  small  intestine 
has  by  compression  become  displaced  and  is  often  not  readily  found. 
In  such  cases  the  distention  of  the  bowel  from  below  will  indicate 
to  the  surgeon  at  once  the  location  and  length  of  the  intestine 
below  the  seat  of  the  obstruction,  and  will  enable  him  to  search  for 
the  obstruction  from  below  upward.  The  manipulation  of  the 
healthy  intact  portion  of  the  intestinal  canal  in  tiic  search  for  the 
obstruction  is  by  far  a  less  hazardous  procedure  than  the  handling 
of  the  distended  portion  above  the  obstruction  rendered  paretic,  ex- 
ceedingly vascular,  and  much  softened  by  the  obstruction.  In  cases 
where  we  suspect  the  presence  of  a  perforation,  inflation  with  hy- 
drogen gas  or  air  will  demonstrate  not  only  its  existence,  but  also 
its  location.  Invagination  is  rare  above  the  ileocecal  valve,  and  its 
location  can  be  determined  by  inflation  with  hydrogen  gas  or  air, 
and,  if  resorted  to  early,  it  may  prove  the  means  of  effecting  reduc- 
tion. In  ileocecal  and  colonic  invagination  slow  and  persistent  dis- 
tention of  the  colon  with  hydrogen  gas,  with  the  patients  com- 
pletely under  the  influence  of  chloroform,  is  the  .safest  and  most 
efficient  means  of  effecting  reduction,  and  should  always  be  resorted 
to  whenever  these  conditions  are  recognized  or  even  susfjectcd. 
Rectal  inflation  as  ordinarily  practised,  by  forcing  air  into  the  rec- 
tum with  bellows  or  a  Davidson's  syringe,  is  not  devoid  of  danger, 
as  the  force  employed  can  not  be  accurately  regulated  or  estimated. 
Hryant  has  collected  twenty  cases  of  invagination  treated  by 
inflation,  in  three  of  which  it  |)roduced  rupture  of  the  bowel  below 
the  invaginated  jjortion,  while  in  a  fourth  the  child  died  in  collapse 
shortly  after  the  inflation.  He  does  not  look  upf)n  inflation  as  a 
proper  and  safe  method  of  treatment  in  ca.ses  of  acute  invagination, 
and  in  the  subacute  form  it  should  be  resorted  to  only  within  the 
48 


754  INTESTINAL    OBSTRUCTION. 

first  three  days,  because  later  on  changes  in  the  bowel  are  almost 
certain  to  have  taken  place  which  would  render  this  measure  fruit- 
less and  probably  dangerous. 

Knaggs  reports  the  particulars  of  eight  cases  of  invagination 
where  forcible  distention  of  the  bowel  by  air  or  water  was  the  cause 
of  rupture  or  other  serious  injury  to  the  bowel.  These  cases  show 
that  this  method  of  treatment  is  attended  by  great  risk  to  children 
less  than  one  year  of  age,  as  six  of  the  eight  cases  in  which  harm 
resulted  were  children  less  than  eight  months  old.  In  Symond's 
case  the  abdomen  was  opened  at  once  after  the  rupture  had  taken 
place,  and  the  rupture  was  sutured.  The  child,  however,  was  too 
exhausted  to  rally  from  the  operation,  but  at  the  necropsy  the 
sutured  wound  was  found  closed. 

Metallic  instruments  should  never  be  used.  A  case  recently 
came  under  my  observation  where  a  physician  attempted  to  dilate 
a  stricture  of  the  large  intestine  with  a  metallic  instrument.  He 
perforated  the  bowel  below  the  sigmoid  flexure,  and  the  patient 
died  in  less  than  twenty-four  hours  from  shock  and  peritonitis. 

Tubage  is  occasionally  resorted  to  as  a  diagnostic  and  therapeutic 

resource.  If  a  rectal  tube  (Fig. 
477)  is  not  available,  a  large  Nela- 
ton  catheter  or  the  stomach-tube 
will  serve  as  a  useful  substitute. 
Force  should  never  be  used  dur- 
ing the  insertion  of  the  tube,  and 
the  procedure  is  much  facilitated 
and  made  more  effective  by  plac- 
ing the  patient  in  the  knee-chest 
Fig.  477-— Plain  elastic  rectal  tube.         position.      Some   authors  Suggest 

the  introduction  of  a  rectal  tube 
in  the  treatment  of  obstruction  below  the  ileocecal  valve,  as  first 
practised  by  O'Bierne,  and  claim  that  with  it  they  have  reached 
the  cecum,  but  Treves  assures  us  that  he  has  made  numerous  ex- 
periments on  the  cadaver  and  has  never  succeeded  in  passing  it 
further  than  the  sigmoid  flexure.  Kelly  has  recently  shown  that 
by  placing  the  patient  in  proper  position  his  sigmoidoscope  can  be 
passed  into,  if  not  beyond,  the  sigmoid  flexure  by  careful  manipu- 
lation of  the  instrument. 

The  legitimate  indications  for  tubage  of  the  colon  are  the  follow- 
ing : 

1.  Detection  and  location  of  obstruction  below  the  sigmoid 
flexure. 

2.  To  relieve  gaseous  distention  of  the  colon. 

3.  To  administer  high  nutrient  enemata  in  cases  where  it  be- 
comes necessary  to  maintain  the  strength  of  the  patient  by  this 
method  of  feeding. 

Manual  exploration  of  the  rectum  as  a  means  of  diagnosis  was 
devised  and  first  practised  by  Simon.      This  method  of  exploration 


TAXIS    AND    MASSAGE.  755 

is  applicable  onl\-  in  the  adult.  Simon  and  his  numerous  followers 
claim  that  the  hand  can  be  introduced  sufficiently  far  to  enable  the 
surgeon  to  palpate  most  of  the  abdominal  organs.  Nussbaum 
asserts  that  he  has  felt  more  than  once  the  tip  of  the  sternum 
with  the  hand  employed  in  the  manual  exploration  by  the  rectum. 

Wagstafif  places  great  stress  on  the  importance  of  manual  explor- 
ation by  the  rectum  as  a  diagnostic  measure,  as  appears  from  one 
of  his  conclusions  :  "  That  the  causes  of  obstruction  can  generally 
be  determined  by  the  history  of  present  and  past  illnesses  and  by 
thorough  external  examination,  and  that  manual  exploration  by  the 
rectum  is  certainly  the  greatest  advance  in  our  means  of  diagnosis." 
The  glowing  accounts  of  the  value  of  this  method  of  exploration 
were  soon  followed  by  the  report  of  disastrous  consequences,  such 
as  rupture  of  the  bowel  and  permanent  loss  of  function  of  the 
sphincter  muscles.  Manual  exploration  by  the  rectum  should  be 
undertaken  only  by  surgeons  with  small  slender  hands,  and  the 
examination  should  be  made  with  the  patient  fully  under  the  influ- 
ence of  an  anesthetic,  and  always  with  the  utmost  care  and  gentle- 
ness. This  method  of  examination  will  enable  the  surgeon  to 
ascertain  the  location  and  nature  of  obstructions  below  the  sigmoid 
flexure,  the  existence  of  volvulus  at  the  sigmoid  flexure,  and  to  de- 
termine the  presence  of  pathologic  conditions  in  the  pelvis  that  might 
have  caused  the  obstruction.  As  a  therapeutic  measure  this  pro- 
cedure can  be  employed  in  the  removal  of  foreign  bodies  or  an 
enterolith  within  reach  of  the  hand,  and  in  the  reduction  of  some 
cases  of  intussusception  in  the  adult  where  the  invaginated  portion 
of  the  bowel  has  passed  beyond  the  sigmoid  flexure. 

Taxis  and  massage  have  a  limited  range  of  usefulness  in  the 
treatment  of  noninllanimatory  dynamic  intestinal  obstruction — that 
is,  when  procedures  are  to  be  restricted  entirely  to  cases  in  which 
the  obstruction  is  caused  by  atony  of  the  bowel-wall,  usually  the 
result  of  long-standing  coprostasis. 

Hutchinson  advocates  what  he  terms  abdoniiiial  taxis  under  an 
anesthetic.  By  abdominal  taxis  he  means  a  thorough  kneading  of 
the  abdomen,  with  inversion  of  the  patient,  shaking  him,  tossing  him 
in  a  blanket,  and  a  variety  of  rough  performances,  the  object  being 
to  di.slodge  the  bowel  or  untwist  the  volvulus.  At  the  same  time 
he  advi.ses  large  cnemata  and  cathartics.  If  these  means  do  not 
lead  to  the  desired  result,  he  waits  and  keeps  the  patient  on  a  low 
diet,  and  administers  opium  or  belladonna  internally,  and  subse- 
quently repeats  theabd(jminal  taxis.  He  reports  a  number  of  cases 
successfully  treated  by  this  method.  It  is  doubtful  if  any  surgeon 
at  the  present  time  could  be  found  who  would  be  willing  to  subject 
Ins  patients  to  such  primitive  treatment  as  advistcl  by  Hutchinson. 
In  mo.st  forms  of  intestinal  oixstruction  such  treatnnnt  is  not  only 
un.scientific  and  useless,  but  attended  by  great  risk  to  life,  as  the 
violent  movements  would  not  only  aggravate  the"  mechanical  diffi- 
culties that  have  caused  the  ob.struction,  but  might  produce-  rupture 


^7^6  INTESTINAL    OBSTRUCTION. 

of  the  distended  intestine,  and  could  not  fail  in  causing  exacerbation 
of  the  vascular  disturbances. 

Streubel  succeeded,  in  a  boy  eleven  years  of  age  suffering  from 
intestinal  obstruction  due  to  the  impaction  of  a  mass  of  cherry- 
stones above  the  ileocecal  valve,  in  removing  the  cause  of  obstruc- 
tion by  submitting  the  swelling  to  gentle  massage  frequently 
repeated. 

Marotte  gives  an  account  of  a  case  of  acute  intestinal  obstruc- 
tion that  had  lasted  for  some  days  when  fecal  vomiting  set  in,  and 
in  which  the  usual  internal  treatment  with  opiates  and  chloroform 
afforded  no  relief,  which  was  promptly  cured  by  palpation  of  the 
abdomen,  made  for  the  purpose  of  locating  the  seat  of  obstruction. 
The  patient  experienced  a  sensation  at  the  time  as  though  the 
obstruction  had  given  way,  and  soon  afterward  had  a  number  of 
evacuations  in  which  a  gall-stone  the  size  of  a  walnut  was  found. 
This  author  refers  to  five  cases  of  intestinal  obstruction  caused  by 
the  presence  of  gall-stones,  collected  by  Fauconneau-Dufresne. 
One  of  these  cases  came  under  the  observation  of  Mayo.  In  this 
case  the  gall-stone  was  also  dislodged  by  palpation,  followed  by 
cessation  of  the  symptoms  of  obstruction  and-  recovery  of  the 
patient.  The  remaining  four  patients  died.  In  cases  of  fecal 
accumulation  in  any  portion  of  the  large  intestine  from  the  cecum 
to  the  sigmoid  flexure,  unattended  by  inflammation  and  giving  rise 
to  symptoms  of  obstruction,  and  not  amenable  to  irrigation  of  the 
colon,  massage  and  taxis  should  be  made  while  the  patient  is  under 
the  influence  of  an  anesthetic,  so  as  to  enable  the  operator  to  break 
up  the  mass  and  to  force  it  onward  in  the  interior  of  the  bowel  to  a 
point  where  the  peristaltic  action  is  more  active. 

Puncture  of  the  intestine  is  not  countenanced  by  surgeons  at  the 
present  time  as  a  remedial  measure  in  the  treatment  of  intestinal 
obstruction,  but  the  general  practitioner,  in  exceptional  and  well- 
selected  cases,  will  have  occasion  to  make  use  of  it ;  consequently 
a  few  remarks  on  this  much-abused  semi-medical  subject  will  not 
be  out  of  place  here. 

Advanced  cases  of  intestinal  obstruction  are  always  attended  by 
great  distention  of  the  bowel  on  the  proximal  side  of  the  obstruction, 
a  condition  that  causes  increased  intra-abdominal  pressure.  The 
tympanitic  distention  of  the  abdomen  may  be  so  great  as  to  destroy 
life  by  the  suspension  of  important  functions  from  mechanical  pres- 
sure. The  diaphragm  is  pushed  upward  so  far  that  death  may  ensue 
from  asphyxia,  or  the  circulation  is  so  far  impeded  by  compression 
of  the  heart  as  to  cause  death  from  syncope.  Great  distention  of 
the  intestines  on  the  proximal  side  of  the  obstruction  also  aggra- 
vates the  mechanical  difficulties  which  have  caused  the  obstruction, 
as  the  distended  bowel  under  such  circumstances  forms  numerous 
flexions  which  interfere  with  the  free  passage  of  its  contents  as  far 
as  the  obstruction  ;  at  the  same  time,  the  distended  coils  may  ren- 
der the  bowel  less  permeable  at  the  seat  of  obstruction  by  compres- 


PUNCTURE    OF    THE    INTESTINE.  y^y 

sion.  The  anxiety  with  which  surgeons  look  upon  extensive  tym- 
panites following  the  course  of  intestinal  obstruction  is  universal  ; 
hence  it  is  only  natural  that  for  a  long  time  it  has  been  customary  to 
make  attempts  at  affording  relief  by  puncturing  the  distended  bowel 
through  the  abdominal  wall.  A  small  trocar  was  usually  employed 
for  this  purpose,  and  since  the  introduction  of  the  hypodermic 
needle  and  the  aspirator,  a  hollow  needle  of  one  of  these  instruments 
has  been  used.  Cases  have  been  reported  where  repeated  punctures 
not  only  afforded  relief,  but  finally  led  to  a  permanent  cure.  In 
some  instances  the  cannula  of  a  trocar  after  puncture  was  allowed 
to  remain  until  a  fecal  fistula  had  been  established.  An  intestine 
distended  to  the  extent  of  giving  rise  to  distressing  and  dangerous 
intra-abdominal  pressure  is  always  in  a  paretic  condition,  unable  to 
expel  its  contents,  and  whatever  escapes  through  a  needle  or  the 
cannula  of  a  trocar,  is  expelled  by  the  contraction  of  the  abdominal 
wall.  This  applies  not  only  to  the  liquid,  but  also  to  the  gaseous 
contents.  I  have  repeatedly  satisfied  myself  during  operations  on 
the  living  subject,  and  in  animals  where  the  obstruction  was  caused 
artificially,  that  mere  puncture  empties  only  a  limited  space — not 
more  than  from  .si.x  to  eight  inches  on  each  side  of  the  puncture. 
If  aspiration  is  practised  at  the  same  time,  the  effect  is  doubled  ; 
further  evacuation  is  arrested  by  flexions  among  the  distended  coils 
and  vahular  closure  of  the  collapsed  segment  of  the  intestine  at  the 
terminus  of  the  evacuated  area.  The  recorded  results  of  puncture 
of  the  inte.stine  represent  largely  only  the  successful  cases,  while  the 
numerous  failures  seldom  find  their  way  into  literature.  Puncture 
of  a  healthy  intestine  with  a  needle  of  moderate  .size  is  never  fol- 
lowed by  extra va.sation,  as  the  irritation  incident  to  the  puncture 
always  produces  muscular  contractions  that  .start  from  the  point  of 
puncture  and  at  once  obliterate  the  canal  made  by  the  needle. 
Puncture  of  a  paretic  intestine  is  always  attended  by  great  risk  of 
extravasation,  as  the  mu.scular  coat  has  lo.st  its  tonicity,  and  the 
track  of  the  needle  or  trocar  is  slower  in  closing  or  remains  perma- 
nently patent.  Numerous  cases  have  been  reported  where  a  mere 
needle  puncture  gave  rise  to  escape  of  fecal  contents  into  the  perito- 
neal cavity.  As  the  removal  of  the  tympanites  is  the  means,  only 
in  exceptional  cases,  of  removing  the  cau.se  of  obstruction,  and  as 
the  puncture  of  a  distended  paretic  intestine  is  never  devoid  of  risk 
of  causing  fecal  extravasation,  the  legitimate  indications  for  puncture 
of  the  intestine  are  extremely  limited.  If  employed  at  all,  puncture 
is  ap[)licable  only  to  cases  where  no  mechanical  obstruction  is  pres- 
ent and  where  the  rapid  distention  of  the  abdomen  in  itself  consti- 
tutes an  imminent  source  of  danger.  Puncture  should  never  be 
resorted  to  witii  a  view  to  removing  liquid  contents  ;  its  use  should 
be  limited  to  the  evacuation  of  gases.  For  this  purpo.sc  one  of  the 
smaller  needles  of  an  aspirator  should  be  used.  The  pf>int  of  the 
needle  should  be  sharp,  so  that  it  can  readily  be  pa.s.sed  through  the 
intestinal  wail.      I  he  needle  should  always  be  disinfected  thoroughly 


758  INTESTINAL    OBSTRUCTION. 

by  boiling  in  soda  solution.  The  puncture  should  be  made  at  the 
most  prominent  point,  and  the  instrument  pushed  boldly  forward 
until  all  resistance  is  overcome.  As  soon  as  the  gas  escapes, 
the  intra-abdominal  pressure  should  be  increased  by  gentle  and 
uniform  compression  of  the  abdominal  walls.  As  soon  as  gas 
ceases  to  escape,  aspiration  should  be  made  and  continued  as  long 
as  anything  can  be  evacuated  and  until  the  needle  is  withdrawn,  but 
not  at  the  time  it  is  withdrawn.  Should  it  be  possible  to  ascertain 
the  location  and  direction  of  the  part  of  the  intestine  to  be  punc- 
tured, it  is  advisable  to  make  the  puncture  obliquely  in  the  long 
axis  of  the  bowel,  so  as  to  guard  more  effectually  against  extrava- 
sation. 

Electricity,  properly  applied,  and  especially  in  conjunction  with 
scientific  massage,  is  a  valuable  remedy  in  the  treatment  of  intes- 
tinal obstruction  caused  by  atony  and  relaxation  of  the  muscular 
coat  of  a  noninflammatory  origin.  It  is  worse  than  useless  in  dy- 
namic obstruction  of  an  inflammatory  nature  and  in  obstruction 
caused  by  permanent  mechanical  conditions. 

Operative  Treatment. — Since  laparotomy  for  other  indications 
has  became  an  established  and  frequently  practised  procedure,  a 
number  of  the  bolder  and  more  aggressive  surgeons  have  resorted 
to  direct  measures  for  the  relief  of  intestinal  obstruction,  but,  like 
all  serious  operations  for  otherwise  incurable  and  fatal  affections,  its 
general  application  has  met  with  strong  opposition  not  only  by  the 
laity,  but  also  by  the  profession.  The  appalling  mortality  that  has 
attended  the  operation  in  the  hands  of  even  the  most  competent 
surgeons  has  been  quoted  in  the  discussions  of  this  subject  in  medi- 
cal societies  as  a  sufficiently  strong  argument  in  favor  of  nonopera- 
tive  interference.  In  this  regard  the  history  of  laparotomy  for  intes- 
tinal obstruction  is  only  a  repetition  of  the  history  of  ovariotomy. 
During  the  early  practice  of  the  latter  the  mortality  was  so  great  that 
the  operation  was  condemned  and  denounced  as  a  deliberate  murder 
by  some  of  the  ablest  and  most  influential  surgeons.  Men  who  had 
the  moral  courage  to  perform  ovariotomy  in  the  face  of  such  bitter 
opposition  only  too  often  reaped  a  harvest  of  reproach  for  having 
performed  their  duty  toward  their  patients.  Yet  in  spite  of  all  op- 
position the  good  work  progressed  until,  by  an  improved  technic, 
and  more  especially  by  the  introduction  of  antiseptic  surgery,  ova- 
riotomy in  the  hands  of  experts  has  become  one  of  the  safest  ope- 
rations in  surgery.-  To  accomplish  this,  hundreds  of  lives  were 
sacrificed  that  thousands  might  be  saved.  The  early  ovariotomists 
operated  only  on  patients  worn  out  by  the  disease,  and  often  the 
subjects  of  additional  serious  visceral  lesions  caused  by  the  prolonged 
hitra-abdominal  pressure,  the  reason  for  this  being  the  great  mortal- 
ity that  attended  the  operation.  To-day  the  danger  incident  to 
opening  the  abdominal  cavity  under  proper  aseptic  precautions  is  so 
slight  that  patients  suffering  from  ovarian  tumors  are  encouraged  to 
have  them  removed  as  soon  as  their  presence  can  be  diagnosticated, 


OPERATIVE    TREATMENT. 


759 


at  a  time  when  the  general  health  remains  unimpaired — a  change  of 
practice  that  has  still  further  reduced  the  mortality  of  ovariotomy. 
The  mortalit}'  of  laparotomy  for  acute  intestinal  obstruction  will  be 
reduced  to  that  of  other  intraperitoneal  operations  as  soon  as  sur- 
geons will  recognize  the  importance  of  operating  early,  before  the 
patient's  strength  has  been  wasted  by  the  disease,  and  before  the 
parts  involved  in  the  operation  have  undergone  irreparable  textural 
changes. 

The  mortality  of  abdominal  section  in  the  treatment  of  the  dif- 
ferent forms  of  intestinal  obstruction  will  always  be  great,  because 
the  conditions  that  have  caused  the  obstruction  are  often  an  intrinsic 
source  of  danger.  In  others  the  removal  of  the  obstruction  necessi- 
tates an  intestinal  resection  that  in  itself  is  a  vastly  more  serious  ope- 
ration than  the  removal  of  an  ovarian  tumor.  Intestinal  obstruction, 
irrespective  of  its  cause,  is  always  followed  by  a  series  of  consecutive 
pathologic  changes  that,  independently  of  the  partial  or  complete 
interruption  of  the  passage  of  intestinal  contents,  tends  to  destroy 
life.  The  dilatation  of  the  intestinal  tube  on  the  proximal  side  of 
the  seat  of  obstruction  may  give  rise  to  such  a  degree  of  abdominal 
distention  as  to  destroy  life  from  suspension  of  important  function 
by  mechanical  pressure.  In  acute  obstruction  the  violent  peristalsis 
on  the  proximal  side  of  the  occlusion  causes  an  increased  afflux  of 
blood  to  the  portion  of  bowel  the  seat  of  exaggerated  physiologic 
function,  which,  after  cessation  of  peristaltic  action,  remains  as  an 
intense  venous  and  capillary  engorgement.  During  the  paretic 
stage  the  blood-vessels  in  the  intestinal  wall  have  lost  their  extra- 
vascular  support,  hence  transudation  and  exudation  readily  take 
place  into  the  paravascular  tissues,  which,  combined  with  the  capil- 
lary .stasis  attending  this  stage  of  the  inflammatory  process,  often 
result  in  gangrene.  The  intestinal  wall  in  a  state  of  inflammation 
becomes  permeable  to  pathogenic  micro-organisms,  which  arc  always 
present  in  the  intestinal  canal,  and  which,  after  passing  through  the 
entire  thickness  of  its  walls,  enter  the  peritoneal  cavity  and  induce 
.septic  peritonitis — a  frequent  immediate  cause  of  death.  These 
facts  are  cogent  rea.sons  for  adopting  surgical  measures  in  all  cases 
of  intestinal  ob.struction  due  to  mechanical  causes  as  soon  as  a  prob- 
able diagnosis  can  be  made.  If  this  were  done,  the  two  greatest 
.sources  of  immediate  danger  attending  and  following  laparotomy, — 
.shock  and  sei)tic  peritonitis, — if  not  entirely  avoided,  at  least  would 
be  less  likely  to  occur,  and  the  ti.ssues  the  seat  of  operation  would 
be  in  a  favorable  condition  for  direct  treatment  and  repair.  An  ab- 
dominal .section  in  the  treatment  of  intestinal  obstruction  is  always 
necessarily  attended  by  some  shock,  and  it  is  therefore  of  the  utmost 
importance  to  perform  the  operation  at  a  time  when  the  organs  of 
circulation  and  the  nervous  .system  are  .still  in  a  condition  to  re.si.st 
successfully  the  immediate  effects  of  the  operation.  Death  from 
septic  causes  can  be  avoided  only  by  ojjcrating  at  a  time  when  the 
intestinal  canal  at  the  seat  of  ob.struction  and  on  its  i)roximal  .side  is 


y^O  INTESTINAL    OBSTRUCTION. 

Still  in  a  condition  capable  of  resisting  infection  and  of  undergoing  a 
satisfactory  process  of  repair  in  case  it  becomes  necessary  to  incise 
or  resect  during  the  operation.  The  statistics  of  operations  for  intes- 
tinal obstruction  will  improve  as  soon  as  we  shall  be  able,  by  im- 
proved methods  of  diagnosis,  to  make  an  early  positive  diagnosis  and 
to  adopt  in  the  treatment  positive  surgical  measures  before  the  pros- 
pects of  a  recovery  have  been  rendered  improbable,  if  not  impossible, 
by  days  and  weeks  of  useless,  and  worse  than  useless,  internal  medi- 
cation. True  intestinal  obstruction,  whatever  its  cause  may  be,  is  as 
strictly  a  surgical  affection  as  strangulated  hernia,  and  remediable 
only  by  the  same  kind  of  surgical  treatment.  Physicians  should 
recognize  this  fact  and  should  call  a  surgeon  into  counsel  as  soon  as 
a  probable  diagnosis  of  intestinal  obstruction  can  be  made.  To  let  a 
patient  die  of  the  consequences  of  a  removable  cause  of  obstruction 
without  an  operation  is  a  reflection  upon  the  advances  of  modern  ag- 
gressive surgery.  The  difficulties  that  surround  the  diagnosis  and 
the  present  imperfect  technic  of  the  operative  procedures  in  cases  of 
intestinal  obstruction  are  not  only  responsible  for  the  heretofore  late 
operations,  but  also,  to  a  great  extent,  for  the  many  failures.  Ways 
and  means  for  more  accurate  diagnosis  will  have  to  be  devised  by 
more  careful  clinical  observations  and  by  experimental  research  ; 
while  new  and  improved  methods  of  operation  must  be  devised  and 
their  merits  and  safety  tested  by  experiments  on  animals.  I  am  con- 
vinced that  accurate  experimental  work  of  this  kind  will  render  essen- 
tial information  in  the  diagnosis  of  the  obscure  causes  of  obstruction, 
and  will  point  out  more  clearly  the  indications  for  operative  treat- 
ment, while  improved  methods  of  operation  will  have  to  be  studied  ex- 
clusively in  this  manner.  The  obstacles  that  the  surgeon  encounters 
in  the  diagnosis  and  treatment  of  many  cases  of  intestinal  obstruc- 
tion often  appear  insurmountable,  but  they  will  be  greatly  diminished 
in  the  future  by  facts  that  will  be  revealed  by  the  results  of  experi- 
mental investigation.  Abdominal  surgery  was  founded  and  devel- 
oped on  American  soil,  and  in  the  part  referring  to  the  treatment  of 
intestinal  obstruction  ample  scope  is  left  for  the  exercise  of  the  ge- 
nius and  perseverance  of  the  younger  members  of  the  profession  in 
this  country,  who  would  do  honor  to  the  memory  of  our  McDowell, 
our  Sims,  and  our  Gross  by  honest,  faithful,  unselfish,  original  work. 


CHAPTER  XX. 

ENTEROSTOMY. 

The  formation  of  a  fecal  fistula  in  the  treatment  of  intestinal 
obstruction  was  first  recommended  by  Louis  in  1757,  and  was  first 
successfully  performed  by  Renault,  of  Joinville,  in  1787,  and  later 
b\'  Maisonneuve.  Nelaton  revived  the  operation  in  1840.  In  a 
memoir  published  in  1845  Maisonneuve  returned  to  the  subject  and 
boldly  advocated  the  propriet\-  of  resorting  to  this  operation  in  cases 
where  complete  obstruction  is  clearly  established,  whether  from  a 
foreign  bod\',  the  formation  of  strictures,  tumors,  invagination,  or 
whatever  the  cause  might  be,  provided  enteritis  had  not  taken  place 
or  that  the  alarming  symptoms — t}'mpanites,  stercoral  vomiting, 
etc. — had  not  resulted  in  gangrene.  Nelaton  taught  that,  by  open- 
ing the  abdomen  in  the  right  iliac  region  and  seizing  the  first  dis- 
tended coil  that  might  present  itself,  the  surgeon,  almost  without 
exception,  would,  by  suturing  the  bowel  to  the  margins  of  the 
wound  and  incising  it,  establish  the  fistula  near  the  ileocecal  region. 
The  selection  of  the  site  of  operation  and,  to  a  certain  degree,  its 
technic  as  performed  to-day,  are  the  same  as  were  proposed'  by 
Nelaton,  and  consequently  the  operation  continues  to  bear  the  name 
of  this  distinguished  surgeon. 

Nelaton's  right  iliac  enterostomy  is  indicated  in  intestinal  ob- 
struction when  the  patient's  general  condition  is  such  as  to  con- 
traindicate  a  radical  operation  by  laparotomy.  It  is  the  duty  of  every 
practitioiiej'  to  perform  it  in  all  cases  in  which,  from  lack  of  assistance, 
the  extent  of  the  tympanites,  or  the  prostrated  condition  of  the  patient, 
laparotomy  is  out  of  question.  Enterostomy  is  a  life-saving  effort,  and 
as  such  no  patient  should  be  allowed  to  die  without  giving  him  the 
possible  benefits  of  the  operation. 

By  following  the  directions  given  by  Nelaton, — and  no  better 
advice  has  since  been  offered, — the  surgeon  has  no  means  of  select- 
ing the  most  desirable  place  in  the  intestine  for  making  the  opening. 
The  only  rule  laid  down  by  the  text-books,  and  the  only  one  appli- 
cable in  such  a  ca.se,  is  to  secure  in  the  wound  and  open  the  first 
distended  looj)  that  presents  itself  It  not  infrequently  hap|)ens  that 
the  opening  is  made  far  above  the  .seat  of  the  obstruction,  an  occur- 
rence that  is  attended  by  two  immediate  sources  of  danger:  (i) 
Phy.siologic  exclusion  of  a  large  portion  of  the  intestinal  canal, 
which,  in  the  event  of  the  patient's  recovery  from  the  operation  and  the 
cause  of  obstruction  remaining  permanent,  is  followed  In-  marasmus 
which  in  itself  may  prove  the  cau.se  of  a  subsequent  fatal  i.ssue.  (2) 
The  portion  of  the  intestine  between  the  artificial  opening  and  the 
seat  of  the  ob.struction,  being  the  part  that  has  suffered  most  from  the 

76r 


762 


ENTEROSTOMY. 


effects  of  the  obstruction,  remains  distended  and  continues  to  exert 
the  same  deleterious  effects  as  before  the  operation.  These  objections 
should  restrict  the  indications  for  enterostomy  as  much  as  possible, 
but  the  practitioner  meets  with  many  cases  of  intestinal  obstruction 
advanced  beyond  the  legitimate  limits  of  a  radical  operation,  in  which 
the  operation  will  occasionally  save  a  life  that  otherwise  would  be 
lost.  The  operation  can  be  performed  in  less  than  twenty  minutes, 
without  assistance,  with  the  contents  of  a  pocket-case  and  without  a 
general  anesthetic.  Patients  in  whom  this  operation  is  indicated  are 
not  in  a  condition  for  the  safe  administration  of  a  general  anesthetic. 
Schleich's  infiltration  method  will  suffice  in  rendering  the  operation 
painless  or  nearly  so.  Strychnin  by  subcutaneous  injection  and 
alcohol  by  the  rectum  should  always  be  given  fifteen  minutes  to 
half  an  hour  before  the  operation.  After  the  skin  has  been  cocain- 
ized, an  incision  about  three  inches  in  length  is  made,  about  two 

fingers'  breadth 
above  and  parallel 
with  Poupart's  liga- 
ment, commencing 
on  a  level  with  the 
iliac  spine.  The 
muscular  layers  are 
then  anesthetized 
by  a  second  infil- 
tration, when  the 
external  oblique  is 
divided  in  the  di- 
rection of  its  fibers 
to  the  same  extent,  the  wound  is  retracted,  and  the  fibers  of  the  in- 
ternal oblique  and  transversalis  are  separated  with  blunt  instruments. 
The  remaining  structures,  including  the  peritoneum,  are  picked  up 
between  two  dissecting  forceps  and  incised  sufficiently  to  insert  the 
tips  of  both  index-fingers,  when  the  opening  is  enlarged  by  stretch- 
ing. The  first  distended  knuckle  of  small  intestine  that  presents 
itself  in  the  wound  is  then  sutured  to  the  parietal  peritoneum,  using 
for  this  purpose  a.  small,  curved,  round  needle  and  fine  silk.  The 
intestine  is  anchored  in  such  a  manner  that  its  long  axis  corresponds 
with  the  direction  of  the  external  incision.  The  stitches  are  placed 
sufficiently  close  together  to  prevent  the  fluid  feces  that  are  evacu- 
ated later  from  reaching  the  peritoneal  cavity.  The  operation 
should  expose  an  oval  space  of  the  bowel  about  an  inch  in  length 
and  three-fourths  of  an  inch  in  width.  The  external  wound  is 
diminished  in  size  by  suturing  to  the  same  extent,  when  the  intes- 
tine is  incised  transversely  and  the  center  of  each  margin  of  the 
wound  fastened  to  the  skin  on  opposite  sides  by  one  or  two  sutures 
of  silk  inserted  with  an  ordinary  surgical  needle.  The  entire  thick- 
ness of  the  margin  of  the  visceral  wound  is  included  in  each  one  of 
the  external  stitches. 


Fig.  478. — Right  iliac  enterostomy;  peritoneal  sutures. 


ENTEROSTOMY.  ^5^ 

Considerable  gas  and  liquid  feces  will  escape  with  some  force  but 
the  amount  is  often  disappointing  to  the  operator.  The  escape  of 
gas  and  the  flow  of  feces  will  increase  with  the  return  of  peristaltic 
action  on  the  diminution  of  the  intra-intestinal  tension.  The  em- 
ployment of  elastic  catheters  contributes  but  little  to  the  intestinal 
evacuation.  Before  the  bowel  is  incised,  the  sutured  portion  of  the 
wound  should  be  sealed  with  collodion  and  cotton,  and  the  sur- 
rounding surface  of  the  skin  covered  with  vaselin  or  some  other 
fatty  substance  to  protect  it  against  the  irritating  action  of  the  fecal 
discharges.  The  use  of  a  drain  is  superfluous  and  often  harmful 
An  absorbent  loose  dressing,  held  in  place  by  a  bandage,  constitutes 
the  dressing. 

Witzel  has  suggested  that  the  intestinal  fistula  should  be  made 


F'g-  479-— Right  inguinal  enterostomy.     Operation  completed,  showing  the  two  external 
sutures  uniting  the  margins  of  the  intestinal  wound  with  the  skin. 

oblique  in  the  same  manner  as  in  his  operation  for  gastro.stomy. 
Mikulicz  argues  that  such  an  oblique  fistula  will  close  spontaneously 
after  the  object  for  which  it  was  made  has  been  accomplished.  If 
this  expectation  can  be  realized,  one  of  the  greate.st  objections  to 
this  operation — a  permanent  fi.stula — will  be  removed.  If  the  patient 
recovers  and  the  ob.struction  is  not  relieved  spontaneously,  a  radical 
operation  can  be  i)erformed  later,  with  a  good  prospect  of  success, 
and  the  intestinal  fistula  is  closed  at  the  .same  time  or  later.  If 
after  developments  make  it  plain  that  the  obstruction  itself  can  not 
be  removed,  the  intestinal  fistula  remains  i)ermanently  as  an  unavoid- 
able evil  unle.ss  the  continuity  of  the  intestinal  tract  can  be  e.stab- 
lished  by  a  lateral  ana.stomosis. 


764  ENTEROTOMY. 

Enterotomy  is  the  operation  that  has  in  view  the  removal  of  the 
mechanical  obstruction  through  an  incision  of  the  bowel,  followed  by 
immediate  closure  of  the  wound  by  suturing.  If  the  operation  is 
made  on  any  part  of  the  large  intestine  above  the  rectum,  it  is  called 
colotomy.  The  indications  for  this  operation  are  furnished  by  impac- 
tion of  the  lumen  of  the  bowel  by  foreign  bodies  that  can  not  be 
dislodged  by  less  formidable  treatment,  or  by  pedunculated  benign 
tumors,  such  as  adenomata  and  submucous  lipomata.  TJie  visceral 
incision  should  always  be  made  transversely,  and  never  in  the  long 
axis  of  the  bowel,  as  is  usually  recommended,  because  transverse 
wounds  can  be  more  readily  sutured  than  longitudinal  zvounds,  and  the 
operation  is  less  liable  to  be  followed  by  stenosis  of  the  bowel.     The 


Fig.  480. — Obstruction  of  the  jejunum  due  to  gall-stone,  showing  the  contraction  of 
the  muscular  fibers  of  the  intestine  upon  the  stone,  which  is  smaller  in  diameter  than  the 
lumen  of  the  gut  (Mixter's  case;  three-quarters  size). 

only  exception  to  this  rule  is  in  cases  in  which  intestinal  obstruction 
by  impaction  from  a  foreign  body  or  pedunculated  benign  tumor  is 
complicated  by  the  presence  of  a  cicatricial  stricture.  In  such  an 
event  the  incision  is  made  longitudinally,  opposite  the  mesenteric 
attachment,  and  the  wound  is  closed  transversely  in  the  same  man- 
ner and  for  the  same  reasons  as  in  performing  the  operation  for  non- 
malignant  stricture  of  the  pylorus,  according  to  the  method  devised  by 
Heineke  and  Mikulicz. 

In  removing  an  obstructing  pedunculated  tumor  from  the  lumen 
of  the  intestine  the  pedicle  is  transfixed  with  a  needle  armed  with 
fine  silk,  both  halves  are  tied  separately,  and  the  tumor  is  excised 
at  a  safe  distance  from  the  ligatures,  when  the  visceral   wound  is 


COLOSTOMY.  765 

closed  in  the  usual  manner.  In  the  removal  of  mural  tumors  of  a 
benign  nature  not  sufficiently  pedunculated  to  admit  of  the  use  of 
the  ligature,  enucleation  is  the  proper  procedure.  All  bleeding 
points  in  the  bed  of  the  tumor  are  tied,  after  which  the  wound  is 
carefull}'  disinfected  and  closed  transversely  by  suturing  the  mucous 
membrane  and  submucous  fibrous  coat  transversely  with  either  fine 
catgut  or  silk  before  closing  the  visceral  incision  by  Lembert  stitches. 


CHAPTER    XXI 
COLOSTOMY. 


The  operation  of  establishing  an  artificial  anus  in  any  part  of 
the  colon  is  now  generally  known  as  colostomy  instead  of  colotomy, 
as  was  the  case  until  quite  recently.  It  is  intended  to  meet  the 
same  indications  as  enterostomy  in  cases  in  which  the  obstruction  is 
located  in  any  part  of  the  large  intestine  below  the  cecum,  and  in 
which  a  radical  operation  is  inapplicable,  owing  to  the  nature  of  the 
obstruction  or  the  general  condition  of  the  patient.  It  has  become 
a  generally  recognized  surgical  procedure  as  a  palliative  and  life- 
prolonging  operation  in  cases  of  inoperable  malignant  disease  and 
extensive  cicatricial  stricture  in  any  part  of  the  bowel  below  the  sig- 
moid flexure.  If  the  artificial  anus  is  established  at  a  point  corre- 
sponding with  the  cecum,  the  operation  should  be  called  typhlos- 
toviy ;  if  it  involves,  as  it  generally  does,  the  sigmoid  flexure, 
sigmoidostomy .  Sigmoidostomy  has  come  into  favor  of  late  as  a  pre- 
liminary operation  to  excision  of  the  rectum  for  malignant  disease. 
In  extensive  disease  of  the  rectum  necessitating  the  remoxal  of  the 
sphincter  muscles  the  formation  of  a  permanent  artificial  anus  in  the 
left  inguinal  region  has  been  favored  by  a  number  of  surgeons  of 
large  experience.  The  operation  can  be  performed  in  one  or  two  sit- 
tings, according  to  the  general  condition  of  the  patient.  It  is 
argued,  and  for  good  reasons,  that  an  inguinal  anus  is  a  less  objec- 
tionable evil  than  a  .sacral  anus. 

Colostomy  will  always  retain  a  legitimate  place  in  operative  sur- 
gery as  a  palliative  and  life-prolonging  procedure  in  the  treatment  of 
malignant  stenosis  of  the  lower  portion  of  the  colon,  and  in  cases  of 
inoperable  carcinoma  of  the  rectum.  The  recent  advances  in  ab- 
dominal surgery  have  rendered  the  old-fashioned  lumbar  operation 
almo.st  obsolete.  Amu.s.sat's  operation  has  few,  if  any,  stanch  advo- 
cates at  the  present  time.  It  has  held  its  place  in  surgery  in  I':ng- 
land  probably  longer  than  in  any  other  country,  but  is  hardly  ever 
performed  in  Germany,  and  seldom  in  our  own  country.  '1  he 
immediate  risks  to  life  of  inguinal  colo.stomy,  properly  performed, 
are  very  .small.      Allingham  has  jjcrformcd  the  oj)cration  68  times, 


766 


COLOSTOMY. 


with  only  2  deaths,  and  those  were  cases  of  complete  obstruction. 
Cripps  reports  45  cases  with  only  i  death  ;  this  also  was  a  total  ob- 
struction case.  Edwards  has  resorted  to  it  in  16  cases,  with  i 
death  ;  Reeves  reports  65  cases  without  a  death.  Goodsall  had  22 
consecutive  recoveries.  These  statistics,  collected  by  Strauss,  show 
a  death-rate  of  less  than  2  per  cent. 

Cripps  has  called  special  attention  to  the  value  of  temporary 
typhlostomy  in  the  treatment  of  complete  obstruction  of  the  large 
intestine.  He  advises,  first,  that  in  all  cases  if  copious  enemata 
have  failed,  and  neither  the  exact  site  nor  the  cause  can  be  ascer- 
tained, the  abdomen  should  be  opened  on  the  left  side,  over  the 
sigmoid  flexure  ;  if  this  part  of  the  bowel  prove  to  be  below  the 
obstruction,  the  wound  should  be  closed  and  the  cecum  exposed  on 
the  opposite  side.  Secondly,  he  advises  that  a  small  opening  should 
be  made  in  the  distended  cecum  after  stitching  it  to  the  parietal 
peritoneum,  and  that  this  opening  may  be  ultimately  enlarged  or 
permanently  closed,  according  to  the  nature  of  the  obstruction,  as 
shown  by  the  subsequent  progress  of  the  case.  There  are  cases  in 
which  these  suggestions  may  prove  of  value,  but  ordinarily  we  are 
able,  by  resorting  to  the  modern  diagnostic  resources,  to  make  a 
reliable  anatomicopathologic  diagnosis  if  the  obstruction  is  located 
below  the  cecum ;  consequently,  the  necessity  for  establishing  a 
fecal  fistula  below  the  ileocecal  valve  can  arise  only  in  exceptional 
cases. 

Colostomy  as  a  paUiative  operation  is  usually  resorted  to  in  cases 
of  chronic  obstruction  below  the  ileocecal  junction  due  to  malignant 
disease,  cicatricial  stenosis  beyond  the  reach  of  more  conservative 
treatment,  chronic  irreducible  invagination,  and  internal  fecal  fistula 
not  amenable  to  a  radical  operation. 

The  modern  operation  is  performed  by  opening  the  peritoneal 
cavity  in  the  right  or  left  iliac  region,  according  to  the  part  of  the 
large  intestine  that  is  the  seat  of  the  obstruction,  and  one  of  the 
principal  objects  of  the  operation  is  to  terminate  the  intestinal  canal 
at  the  artificial  anus  so  as  to  secure  absolute  physiologic  rest  for  the 
affected  portion  of  the  bowel  below  the  artificial  anus.  If  it  is  the 
intention  to  establish  a  fecal  fistula  only,  the  operation  is  performed 
in  the  same  manner  as  has  been  described  under  the  head  of  Enter- 
ostomy. The  incision  is  made  a  little  longer  and  with  special 
reference  to  avoiding  injury  to  the  muscular  fibers. 

Maydl's  technic  of  anchoring  the  intestinal  loop  in  the  wound 
is  the  one  most  generally  adopted  at  the  present  time  in  establishing 
an  artificial  anus  in  the  left  inguinal  region.  In  the  majority  of  cases 
the  abdomen  is  opened  in  the  manner  indicated  for  the  operation  in 
the  left  inguinal  region.  The  external  incision  is  made  from  three  to 
four  inches  in  length  and  a  finger's  breadth  above  the  external  half 
of  Poupart's  ligament.  The  external  oblique  is  divided  in  the  direc- 
tion of  its  fibers,  and  the  internal  oblique  and  transversalis  are  opened 
to  the  requisite  extent  by  blunt  instruments,  after  which  the  perito- 


OPERATIVE    TECHNIC. 


767 


Fig.  4S1. — Maydl's  left  inguinal  colostomy. 


Ileum  is  divided  between  two  dissecting  forceps.  The  fibers  of  the 
different  muscles  must  be  carefully  preserved,  to  guard  against  pro- 
lapse of  the  artificial  anus  later.  If  the  obstruction  is  located  below 
the  sigmoid  flexure,  there  is  no  difficulty  in  finding,  identifying,  and 
bringing  forward  into  the 
opening  this  part  of  the 
large  intestine,  which  is  usu- 
ally supplied  with  a  long- 
mesentery.  The  longitud- 
inal band  and  the  manner 
of  distribution  of  the  blood- 
vessels serve  as  reliable  land- 
marks in  distinguishing  the 
large  from  the  small  intes- 
tine. In  obese  subjects  it  is 
sometimes  found  difficult,  if 
not  impossible,  to  bring  the 
intestine  sufificienth'  forward 
to  anchor  it  safely  in  the 
wound  by  the  aid  of  Maydl's 
bridge.  U  this  is  the  case, 
suturing  riiust  be  relied  upon 
in  holding  the  loop  in  the 
wound  and  in  securing  the 
neces-saiy  degree  of  flexion.  Ordinarily,  the  sigmoid  flexure  is 
drawn  forward  into  the  wound  until  its  mesenteric  attachment 
is  on  a  level  with  the  external  incision.  Through  a  slit  made  in 
the  mesentery  close  to  the  intestinal  wall  with  a  pair  of  locked 
hemostatic  forceps  is  inserted  a  hard-rubber  cylinder  or  piece  of 
glass  tubing  the  size  of  a  lead-pencil,  four  inches  in  length,  and 
wrapped  in  a  layer  or  two  of  iodoform  gauze.  This  device  holds  the 
intestine  in  the  wound  and  prevents  its  return  into  the  abdominal 
ca\ity.  By  means  of  two  Lembert  stitches 
placed  on  each  side  of  the  prolapsed  loop  and 
below  the  bridge,  the  two  limbs  of  the  flexure, 
in  so  far  as  they  lie  in  the  abdominal  wound, 
are  sewed  together  so  as  to  make  and  main- 
tain an  acute  flexion,  so  essential  a  feature 
in  intercepting  the  fecal  current  completely. 
Some  care  is  neces.sary  in  ])reventing  a  partial 
twist  or  volvulus  of  the  bowel  before  anchor- 
ing it  in  the  wound.  If  this  can  not  be  done 
with  a  sufficient  degree  of  certainty  by  follow- 
ing each  limb  with  the  finger,  the  neces.sary 
information  can  readily  be  obtained  by  inflating  the  bowel  from  the 
rectum,  or  by  the  insertion  of  a  rectal  tube  or  bougie.  It  is  any- 
thing but  a  source  of  .satisfaction  for  the  surgeon  to  find,  on  opening 
the  bowel,  that  the  ccMitents,  contrary  to  his  expeditions,  arc- escap- 


Fig.  482.  —  Sigmoid 
flexure  brought  forward 
into  the  wound,  and  the 
two  limbs  of  the  lf>op 
unitef!  by  two  sutures  be- 
low the  bridge. 


768  COLOSTOMY. 

ing  from  the  lower  instead  of  the  upper  end.  The  base  of  the  intes- 
tinal loop  is  next  sutured  to  the  parietal  peritoneum  with  at  least 
six  fine  catgut  or  silk  sutures.  This  precaution  is  taken  to  prevent 
prolapse  of  the  "small  intestine  should  the  patient  vomit  during  or 
soon  after  the  operation,  and  also  to  serve  as  an  additional  safeguard 
against  peritoneal  contamination  should  it  be  deemed  advisable  to 
complete  the  operation.  Maydl  regarded  this  part  of  the  operation 
as  unnecessary,  but  a  case  in  my  own  practice  in  which  such  prolapse 
occurred  has  taught  me  the  importance  of  this  procedure.  The 
angles  of  the  abdominal  incision  are  sutured  sufficiently  so  that  the 
external  wound  is  in  close  contact  with  the  intestine,  but  without 
giving  rise  to  harmful  circular  constriction.  A  small  circular  dress- 
ing of  iodoform  gauze  and  cotton  is  sealed  with  collodion  to  the  base 
of  the  loop  and  adjacent  skin  to  protect  the  wound  against  infection. 
A  piece  of  gutta-percha  tissue,  four  to  six  inches  square,  with  a 
small  central  opening  to  receive  the  apex  of  the  intestinal  cone,  is 
fastened  to  the  base  of  the  prolapsed  bowel  and  skin  with  collodion. 
If  the  symptoms  are  urgent,  the  bowel  is  divided  transversely  over 
the  bridge  with  the  knife  or,  preferably,  with  the  Paquelin  cautery, 
to  the  extent  of  from  one-third  to  one-half  of  its  circumference.  If 
the  symptoms  are  not  severe,  it  is  safer  to  postpone  the  visceral  in- 
cision for  from  twenty-four  to  forty-eight  hours,  when  it  can  be  made 
almost  painlessly  without  the  use  of  a  general  or  even  a  local  anes- 
thetic. 

Drains  inserted  into  the  bowel  do  more  harm  than  good.  Drains 
were  inserted  into  each  end  of  the  bowel  by  Konig  and  Hahn, 
leaving  the  bowel  in  such  a  condition  that  both  ends  could  be 
flushed  freely ;  but  this  can  be  done  with  equal  facility  without 
tirains.  Madelung  advises  that  in  cases  in  which  it  becomes  neces- 
sary to  establish  a  permanent  artificial  anus  the  bowel  should  be 
completely  cut  across  and  the  lower  end  closed,  but  this  is 
objectionable,  as  it  interferes  with  proper  cleansing  of  the  excluded 
portion  of  the  bowel. 

The  modern  operation  of  colostomy  is  indicated  in  cases  of  con- 
genital atresia  of  the  rectum  when  the  bowel  can  not  be  readily 
reached  from  below  ;  also  in  cases  of  carcinoma  of  the  sigmoid  flex- 
ure or  of  the  rectum  not  amenable  to  a  radical  operation.  Finally, 
the  operation  might  become  necessary  in  irreducible  colic  invagin- 
ation in  which,  for  anatomic  reasons,  resection  or  anastomosis  can 
not  be  done. 

If  it  is  the  intention  to  establish  a  permanent  artificial  anus  and 
the  progress  of  the  case  is  satisfactory,  the  bowel  can  be  cut  through 
completely  in  two  or  three  weeks,  the  bridge  serving  a  useful  pur- 
pose as  a  guide  in  making  this  incision  ;  a  few  sutures  will  serve  to 
secure  the  cut  proximal  end  to  the  skin.  Should  the  artificial  anus 
be  only  a  temporary  one,  the  incision  in  the  intestine  is  made  in  a 
longitudinal  direction.  When  it  has  become  desirable  to  close  the 
artificial    opening,    the  bridge  is   removed,   after   which   the   bowel 


OPERATIVE    TECHNIC. 


769 


retracts  and  the  opening  olten  closes  without  any  further  treatment 
If  the  adhesions  are  too  firm  for  this,  they  are  removed  and  the 
bowel  IS  sutured  and  returned  into  the  peritoneal  cavity  I  auen 
stein  accomplishes  the  same  object  in  establishing  an  artificial  anus 
uthout  the  bridge,  by  suturing  first  the  peritoneum  to  the  skin  thus 
lining  the  external  incision  by  peritoneum,  then  drawing  out  a  Iood 
of  intestine,  and  closing  the  parietal  wound  by  sutures  passino- 
through  the  mesocolon  of  the  prolapsed  portion  of  intestine,  which 
IS  thus  fastened  in  the  abdominal  incision  ;  next  the  serosa  of  each 
hmb  of  the  prolapsed  loop  is  stitched  through  its  entire  circumfer- 
ence to  the  parietal  peritoneum. 

An  interesting  discussion  has  arisen  lately  in  Germany  in  regard 
to  a  step  in  the  operation  of  colostomy  that  was  described  by  Knie 


'■'g-  483. — Artificial  anus  after  Maydl's  operation. 


So  far  the  operation  has  been  done  only  on  dogs.  It  consists  in  open- 
mg  the  abdomen  transversely  in  the  region  of  the  transverse  colon, 
stitching  the  peritoneum  to  the  edges  of  the  wound,  drawing  out  the 
colon,  making  a  slit  in  the  mesocolon  near  the  gut  witii  a  blunt  in- 
.strumcnt,  and  closing  the  abdominal  wound  with  two  or  three 
sutures,  which  are  passed  through  the  slit  in  the  me.socolon.  The 
object  of  this  is  to  .secure  a  loop  of  the  colon  outside  of  the  abdom- 
inal cavity.  This  loop  is  to  be  .stitched  carefully  at  each  side  to  tiie 
edge  of  the  (now)  two  additional  openings,  after  which  it  is  to  be 
opened  by  an  incision,  or,  if  the  .symptoms  are  not  urgent,  the  inci- 
sion is  po.stponed  for  a  few  days  until  the  peritoneal  cavity  has  been 
shut  off  by  adhcsion.s.  As  a  general  thing.  Lauen.stcin's  operation 
49 


^^O  ABDOMINAL   SECTION. 

will  be  found  simplest  and  should  receive  the  preference  in  ordinary 
cases. 

If  the  artificial  anus  is  made  for  an  incurable  condition,  it  would 
appear  advisable  to  divide  the  bowel  completely  when  it  is  first 
opened,  and  fasten  each  end  to  the  skin  by  sutures  separately, 
leaving  a  bridge  of  skin  three-quarters  of  an  inch  wide  between  them. 


CHAPTER  XXII. 
ABDOMINAL  SECTION. 


A  RADICAL  operation  in  the  treatment  of  intestinal  obstruction 
embraces  the  fulfilment  of  two  principal  indications:  (i)  The 
removal  or  rendering  harmless  of  the  cause  of  obstruction  and  (2) 
the  immediate  restoration  of  the  continuity  of  the  intestinal  canal. 
To  meet  the  first  indication  the  cause  of  the  obstruction  must 
be  found,  its  nature  determined,  and,  whenever  advisable  or  prac- 
ticable, it  is  removed,  a  step  in  the  operation  that  may  be  very  easy 
or  may  demand  a  most  formidable  and  serious  undertaking,  more 
especially  in  cases  where  the  pathologic  conditions  that  have  given 
rise  to  the  obstruction  are  of  such  a  nature  as  to  constitute  in  them- 
selves an  imminent  or  remote  source  of  danger — as,  for  instance, 
malignant  disease  or  gangrene  of  the  bowel  from  constriction.  Ab- 
dominal section  in  the  treatment  of  intestinal  obstruction  has  so  far 
been  attended  by  a  fearful  mortality,  owing  to  the  fact  that  most 
operations  were  performed  when  the  patients  were  in  collapse  or 
when  the  parts  involved  in  the  obstruction  had  undergone  advanced 
and  often  irreparable  pathologic  conditions. 

Ashhurst  tabulated  57  cases  of  laparotomy  for  acute  intestinal 
obstruction  from  other  causes  than  intussusception,  from  which 
it  will  be  seen  that  only  1 8  terminated  favorably,  so  that  at  that 
time  the  mortality  of  laparotomy  in  cases  of  intestinal  obstruction 
other  than  intussusception  was  over  68  per  cent.  Most  of  these 
operations  were  performed  without  aseptic  precautions. 

Schramm  has  collected  190  cases  of  intestinal  strangulation 
treated  by  laparotomy,  including  3  cases  observed  by  himself  in  the 
practice  of  Mikulicz.  He  alludes  to  the  difficulties  encountered  in 
the  diagnosis  of  these  cases,  and  pleads  in  favor  of  early  operative 
interference.  Of  this  number  64.2  per  cent,  died,  the  mortality 
before  the  antiseptic  treatment  of  wounds  being  73  per  cent.,  and 
since  that  time  58  per  cent.  The  cause  of  obstruction  and  the 
death-rate  attending  each  kind  may  be  gleaned  from  the  following 
table : 


ABDOMINAL    SECTION.  77 1 

Invagination 27  times,     8  cured,  19  died. 

Bands  or  intestinal  diverticula 49  "  13  "  36  " 

Adhesions 16     "  7  "  9  '< 

Reduction  en  masse 11  "  6  "  5  ♦' 

Torsions 10  "  i  "  9  " 

Knotting  of  bowel         12  "  4  "  8  " 

Internal  strangulation 12  "  4  "  8  '♦ 

Foreign  bodies 7  "  4  "  3  " 

Neoplasms          38  "  16  "  22  " 

Unknown  causes    ....        8  "  4  "  3  " 

Curtis  has  collected  a  large  number  of  cases  of  intestinal  obstruc- 
tion treated  by  abdominal  section  since  the  year  1873,  consequently 
since  the  antiseptic  treatment  of  wounds  was  introduced.  His  first 
table  shows  a  total  of  328  cases,  with  102  recoveries  and  226 
deaths,  the  percentage  of  mortality  being  68.9 — a  higher  percentage 
than  that  of  Schramm's  collection.  His  third  table  shows  that  in 
10 1  cases  the  failure  of  the  operation  was  due  directly  to  the  un- 
favorable condition  of  the  patient,  who  was  in  a  dying  state  in 
8  cases.  In  the  majority  of  the  cases  with  complications,  41  in  all, 
the  fatal  result  was  also  really  due  to  the  condition  of  the  patient, 
for  the  existence  of  peritonitis  or  gangrene  of  the  bowel  at  the  time 
of  operation  shows  that  there  had  been  too  much  delay  in  resorting 
to  operative  measures,  and  most  of  these  cases  died  a  few  hours 
after  operation.  In  28  cases  the  cause  of  obstruction  was  not  found 
or  could  not  be  removed,  and  in  i  i  the  reports  are  so  defective 
that  the  cause  of  death  can  not  be  ascertained  from  them.  Of  the 
remaining  45  fatal  ca.ses,  13  died  of  shock;  in  three  cases  the  un- 
usual length  of  the  operation  was  probably  the  direct  cause  of  death, 
and  in  17  cases  sepsis,  probably  due  to  the  operation,  was  the  cau.se 
of  death.  In  12  cases  the  cause  could  not  be  definitely  learned, 
but  as  death  followed  in  most  of  them  within  twenty-four  hours 
after  the  operation,  it  was  probably  shock  and  exhaustion.  In  247 
ca.ses  where  the  cause  of  ob.struction  was  removed,  the  mortality  was 
only  62.7  per  cent.;  while  in  47  in  which  it  was  not  done,  the 
mortality  was  86.4  per  cent.  In  41  cases  where  the  obstruction 
con.sisted  of  invagination,  volvulus,  adhesions,  bands,  and  internal 
incarceration,  in  which  the  obstruction  was  not  removed,  not  a  single 
one  recovered,  although  in  16  an  artificial  anus  was  made. 

The  greatest  mortality  attended  cases  where  from  any  cause 
suturing  of  the  bowel  was  made,  attaining  the  extreme  point  of  86.6 
per  cent,  in  45  ca.ses.  The  necessity  for  a  short  operation  is  well 
shown  by  the  cases  collected  by  Curtis,  which  give  a  mortality  of 
57  per  cent,  in  190  cases  in  which  the  operative  interference  was 
limited  to  relieving  the  ob.struction  without  wounding  the  bowel, 
while  it  rose  to  73  per  cent,  in  1  5  ca.ses  in  which  it  became  neces- 
sary to  establish  an  artificial  anus  after  the  obstruction  had  been  re- 
moved, and  to  83  per  cent,  in  48  ca.ses  in  which  the  bowel  had  to 
be  sutured.  In  all  these  ca.ses  the  true  danger  lay  in  the  long 
duration  of  the  operation,  for  death  resulted  from  the  immediate 
effects  of  the  operation  in  most  of  them. 


772  ABDOMINAL    SECTION. 

Improved  aseptic  precautions,  a  better  technic,  and  prophylac- 
tic measures  against  shock  have  done  much  to  reduce  the  former 
alarming  mortality  of  abdominal  section  for  intestinal  obstruction,  as 
is  shown  by  a  more  recent  paper  on  this  subject  by  Obahnski,  based 
on  I  lo  cases  operated  upon  by  himself  Although  in  some  of  these 
cases  the  operation  was  done  as  a  last,  almost  forlorn,  hope,  38 
recovered.  Those  who  oppose  operative  interference  often  quote 
Goltdammer  and  others  who  beHeve  that  surgery  has  done  but 
little  in  saving  Hfe  in  such  cases.  Goltdammer  treated  50  cases  of 
intestinal  obstruction  in  the  Bethany  Hospital,  at  Berlin,  on  the  ex- 
pectant plan  and  by  the  use  of  large  doses  of  opium,  and  of  these, 
I  5  recovered.  There  can  be  but  little  doubt  that  in  most  of  the 
cases  that  recovered  the  obstruction  was  the  result  of  dynamic  and 
not  mechanical  causes.  The  uncertainty  of  the  diagnosis  and  the 
recoveries  attributed  to  internal  treatment  have  done  much  to  main- 
tain the  high  mortality  of  surgical  interference  by  causing  a  delay 
of  the  operation  until  the  complications  arising  from  the  obstructions 
have  become  the  most  formidable  causes  of  danger  to  life. 

The  statistics  given  show  the  value  and  importance  of  an  early 
operation,  as  sometimes  delay  of  only  a  few  hours  will  bring  com- 
plications that  not  only  necessitate  more  time  in  their  removal,  but 
will,  at  the  same  time,  require  a  resection  or  an  anastomosis,  which, 
had  the  operation  been  done  at  an  earlier  date,  might  have  been  obvi- 
ated. The  older  text-books  on  surgery  always  cautioned  the  prac- 
titioner to  postpone  the  operative  treatment  of  a  strangulated  hernia 
for  a  certain  length  of  time,  which  was  often  consumed  in  vain 
attempts  at  reduction  ;  consequently  the  old  statistics  of  herniotomy 
present  a  high  mortality  when  contrasted  with  recent  operations. 
This  striking  contrast  was  brought  about  not  solely  by  an  improved 
technic  or  by  the  introduction  of  antiseptic  surgery,  but  it  is  largely 
owing  to  the  modern  teaching  that  it  is  dangerous  to  delay  an  opera- 
tion, if  the  strangulation  is  not  relieved  by  gentle  taxis  persisted  in 
not  for  hours  and  days,  but  only  for  fifteen  minutes,  and  at  the 
utmost  for  half  an  hour.  ,  Modern  surgery  recognizes  the  safety  of 
an  early  operation  for  strangulated  hernia,  and  the  results  that  have 
been  obtained  have  demonstrated  the  wisdom  of  the  change  in  prac- 
tice. Vain  and  prolonged  attempts  at  reduction  of  a  strangulated 
hernia  aggravate  the  causes  that  have  produced  the  strangulation 
and  hasten  the  pathologic  changes  in  the  strangulated  intestinal  loop 
that  arise  from  the  strangulation.  If  delay  is  dangerous  in  a  case 
of  strangulated  hernia,  what  can  we  expect  of  a  laparotomy  for 
intestinal  obstruction  when  postponed  until  the  patient  has  been 
exhausted  or  the  local  conditions  necessitate  complicated  operative 
measures  ?  In  strangulated  hernia  the  destructive  changes  in  the 
constricted  intestinal  loop  affect,  by  continuity  and  contiguity,  pri- 
marily only  a  Hmited  peritoneal  surface,  while  in  intestinal  obstruc- 
tion the  seat  of  obstruction  is  in  direct  communication  with  the 
entire  peritoneal  cavity,  which  becomes  the  ^eat  of  a  rapidly  fatal 


ABDOMINAL   SECTION. 


771 


septic  inflammation  if  gangrene  or  perforation  has  caused  the 
mflammation.  A  recent  intestinal  obstruction  due  to  a  chano-e 
of  visceral  relations,  such  as  flexion,  volvulus,  and  invagination, If 
subjected  to  operative  treatment  before  consecutive  pathologic 
changes  have  occurred,  would  ofier  but  little  difficulty  to  mechanical 
correction  of  the  displacement,  and,  as  in  such  cases  the  intestinal 
tube  would  be  in  a  healthy  intact  condition,  the  danger  of  the  opera- 
tion would  not  be  greater  than  that  of  an  ordinar)-  oxariotomy. 
Enough  has  been  said  in  favor  of  an  early  operation  in  all  cases 
where  the  signs  and  symptoms  indicate  the  existence  of  an  obstruc- 
tion that  does  not  yield  to  milder  measures.  Intestinal  obstruction 
is  a  surgical  lesion  in  every  sense  of  the  word,  and  should  be  treated 
from  the  very  beginning  upon  common-sense  surgical  principles. 
To  temporize  with  such  cases  by  the  administration  of  uncertain 
drugs  must  be  looked  upon  as  evidence  of  ignorance  or  unpardon- 
able timidity.  The  treatment  of  a  case  of  intestinal  obstruction 
upon  the  expectant  plan  until  gangrene  or  perforation  has  taken 
place,  \\hich,  if  submitted  in  time  to  proper  surgical  treatment, 
might  have  been  relieved  by  one  stroke  of  the  scissors,  should  be 
considered  as  gross  negligence  for  which  the  modern  aggressive 
physician  and  surgeon  can  offer  no  justification  or  apology.  The 
future  progress  of  abdominal  surgery  will  conquer  the  difficulties 
that  now  surround  the  diagnosis  and  treatment  of  intestinal  obstruc- 
tion. Experimental  research  and  more  careful  and  accurate  clinical 
observation  will  solve  the  difficult  problems  that  now  surround  us  in 
this  as  yet  imperfectly  explored  field  of  surgical  labor.  Laparotomy 
for  intestinal  obstruction  should  not  be  undertaken  by  every  tyro  in 
surgery.  The  one  who  undertakes  it  should  be  master  of  the  situa- 
tion, familiar  with  every  detail  of  the  technic  of  different  operative 

'  procedures,  and  fully  conversant  with  the  manifold  complications 
with  which  he  may  be  confronted.  Every  po.s.sible  contingency 
must  be  fully  considered  before  the  abdomen  is  opened,  as  this  is  an 
operation  where  unnecessary  hesitation  and  loss  of  time  weigh 
heavily  in  the  balance  on  the  side  of  failure.  Like  other  abdominal 
operations,  laparotomy  can  not  be  mastered  in  the  lecture-room  or 
even  under  the  tuition  of  experienced  surgeons.  Those  who  expect 
to  perform  tiiis  operation  must,  in  the  first  place,  have  a  perfect 
knowledge  of  the  structure  and  relations  of  all  the  abdominal  organs 
in  conditions  of  health  and  di.sease,  and  must  acquire  the  neces.sary 
operative  skill  on  the  cadaver,  and  then,  wliat  is  .still  more  important, 
should  make  the  more  imj^ortant  operations  on  the  living  animal. 
It  is  not  necessary  or  even  desirable  that  every  phy.sician  should 
become  a  laparotomi.st,  but  practitioners  di.stant  from  medical  centers 
should  intcre.st  them.selves  in  this  branch   of  surgery  and  prepare 

them.selves  to  meet  such  emergencies.  Unlike  a  patient  suffering 
from  an  ovarian  tumc^r.  patients  affected  with  acute  intestinal  ob- 
struction can  not  be  transptjrted  great  distances,  and  as  loss  of  time 

leads  to  disa.strous  con.sequences,  it  is  not  always  possible  to  .secure 


774  ABDOMINAL    SECTION. 

from  a  distance  the  services  of  a  surgeon  versed  in  abdominal  sur- 
gery, and  for  such  contingencies  every  physician  should  hold  him- 
self in  readiness. 

The  technic  of  intestinal  resection,  anastomosis,  and  suturing 
can  be  acquired  by  operations  on  the  fresh  intestines  of  dead  ani- 
mals. Unnecessary  experiments  should  not  be  made  on  the  living 
animal,  as  this  would  be  an  unpardonable  cruelty  :  a  few  operations 
on  the  living  intestine  will  suffice  to  prepare  the  physician  properly 
for  emergency  operations  of  this  kind. 

Preparations  for  the  Operation. — The  most  careful  and  perfect 
preparations  should  be  made  for  the  operation.  The  presence  of  at 
least  three  reliable  and  inteUigent  assistants  is  an  absolute  necessity. 
As  an  eventration  may  become  necessary  and  exposure  of  the 
intestines  to  a  cool  atmosphere  is  productive  of  shock,  an  equable 
temperature  of  from  8o°  to  85°  F.  should  be  maintained  in  the 
operating  room  from  the  beginning  to  the  end  of  the  operation. 
Opinions  among  operators  may  still  differ  as  to  the  wisdom  or  even 
propriety  of  using  antiseptics  in  a  healthy  peritoneal  cavity,  but  no 
one  at  the  present  day  would  have  the  courage  to  oppose  the  use  of 
stinctest  aseptic  precautions  in  securing  an  aseptic  condition  for  every- 
tliing  that  zvill  come  in  contact  with  the  ivound  of  the  peritoneal  sur- 
faces. The  operating  room  must  be  cleared  of  everything,  leaving 
the  walls  and  floor  bare,  and  the  whole  of  its  interior  surface 
washed  with  a  strong  solution  of  sublimate  or  carbolic  acid.  The 
table  and  stands  are  disinfected  in  a  similar  manner.  The  blankets, 
if  not  perfectly  aseptic,  can  be  covered  with  linen  sheets.  Heat  is 
the  most  reliable,  safest,  and  cheapest  sterilizer,  and  can  be  used  for 
the  disinfection  of  towels,  napkins,  instruments,  and  wash-basins. 
The  operator  must  satisfy  himself  of  the  aseptic  nature  of  everything  that 
is  to  be  used  inside  the  peritoneal  cavity.  The  abdomen  of  the  patient 
and  the  operator's  and  assistants'  hands  are  rendered  aseptic  by  wash- 
ing with  potash  soap  and  warm  water,  and  afterward  with  a  i  :  1 000 
solution  of  sublimate.  The  water  used  for  solutions  and  sponges  is 
sterihzed  by  boiling.  For  the  protection  of  prolapsed  intestine,  com- 
presses of  aseptic  gauze  or  napkins  are  better  than  sponges,  and  the 
temperature  of  the  parts  is  maintained,  not  by  pouring  warm  water 
on  the  compresses,  but  by  removing  them  and  applying  new  ones 
wrung  out  of  warm  saline  solution.  The  danger  of  using  corrosive 
sublimate  solution  within  the  peritoneal  cavity  is  well  shown  by 
Kiimmell's  experience.  He  made  nine  laparotomies,  using  for  the 
sponges  a  i  :  5000  solution  of  sublimate,  and  all  the  patients  recov- 
ered without  an  unpleasant  symptom.  Then  he  met  with  two  cases 
of  sublimate  intoxication  in  succession  after  having  used  the  same 
strength  of  the  solution.  One  of  the  patients  died  on  the  fourth  day, 
and  the  postmortem  revealed  intestinal  lesions  characteristic  of  acute 
mercurial  poisoning.  The  other  patient  recovered  after  a  lingering 
illness,  during  which  the  symptoms  of  mercurial  intoxication  were 
well  marked.      He  cautions  against  the  use  of  sublimate  in  debili- 


ANESTHESIA. 


775 


tated,  anemic  individuals  or  in  patients  suffering  from  renal  disease. 
In  cases  where  the  peritoneal  cavity  is  in  a  healthy  aseptic  condition, 
the  use  of  any  of  the  stronger  antiseptics  is  contraindicated.  Several 
gallons  of  hot  sterile  saline  solution  in  an  aseptic  vessel  must  always 
be  provided,  as  this  solution  is  now  the  one  generally  relied 
upon  for  tile  sponges,  compresses,  and  for  flushing  the  abdominal 
cavity  in  cases  requiring  it.  For  the  cases  where  septic  peritonitis, 
suppuration,  gangrene,  or  perforation  exists,  a  2  per  cent,  solution 
of  boric  acid  or  a  saturated  solution  of  salicylic  acid  (0.3  per  cent.) 
should  be  kept  in  readiness  for  flushing  the  abdominal  cavity. 
Bands  of  rubber  or  fine  rubber  tubing  should  always  be  on  hand,  as 
well  as  a  good  assortment  of  aseptic  silk,  well-prepared  catgut,  glass 
drains.  Murphy's  button,  decalcified  perforated  bone  or  vegetable 
plates,  and  a  full  complement  of  needles  and  forceps.  Stimulants 
and  means  to  make  autotransfusion  must  never  be  absent,  as  prompt 
interference  when  symptoms  of  shock  make  their  appearance  may 
prove  the  means  of  restoring  the  force  of  the  circulation  until  reac- 
tion can  be  established  by  other  measures. 

Weir  suggests  the  admini.stration  of  a  hypodermic  injection  of 
from  yi-jj-  to  -jvL  of  a  grain  of  atropin  and  a  large  rectal  enema  of 
brandy  before  the  anesthesia,  for  the  purpose  of  increasing  the  force 
of  the  heart's  action.  Subcutaneous  injection  of  strychnin  and  a 
quart  of  hot  saline  solution  administered  by  the  rectum  half  an  hour 
before  the  anesthetic  is  given  will  prove  valuable  in  minimizing  the 
shock  of  prolonged  operations.  During  the  operation  tiie  periph- 
eral circulation  is  best  kept  up  by  placing  the  patient  on  a  rubber  bed. 
filled  with  hot  water,  and  in  the  absence  of  such  a  contrivance  by 
applying  to  the  extremities  warm  blankets  or  rubber  bags  or  bottles 
filled  with  hot  water. 

Anesthesia. — A  number  of  American  surgeons  have  recently 
expressed  a  preference  for  chloroform  to  ether  as  an  anesthetic 
in  abdominal  operations,  as  it  is  less  likely  to  produce  vomiting 
before,  during,  and  after  the  operation.  Another  serious  objection 
to  the  use  of  ether,  especially  in  persons  advanced  in  years,  is  the 
frequency  with  which  bronchitis  is  jjroduced  when  this  anesthetic  is 
used  exclu.sively.  The  use  of  chloroform,  however,  is  al.so  not  free 
from  objection.  The  depressing  effect  of  this  anesthetic  on  the 
action  of  the  heart  is  well  known,  and  as  the  force  of  the  circulation 
is  almost  without  exception  seriously  impaired  in  these  cases,  its 
jjrolonged  use  might  result  in  dangerous  consequences.  The  best 
course  to  pursue  is  to  follow  the  u.se  of  chloroform  by  ether.  The 
addition  of  fifteen  minims  of  nitrite  of  amyl  to  four  ounces  of  chloro- 
form diminishes  in  a  marked  degree  the  depressing  effect  of  the 
latter.  The  retching  and  brcmchorrhea  are  prevented  by  placing 
the  patient  first  under  the  influence  of  chloroform,  and  the  deleterious 
effects  of  the  prr^Ionged  use  of  this  agent  are  avoided  by  keeping 
up  the  narcosis  during  the  operation  with  ether.  From  the  time  the 
first  incision  is  made  until  the  abdominal  wound  is  closed  the  patient 


7^6  ABDOMINAL   SECTION. 

must  be  kept  profoundly  under  the  influence  of  the  anesthetic,  inas- 
much as  any  interruption  will  cause  an  unnecessary  delay  in  the 
operation  and  may  result  in  complications  that  are  not  easily  reme- 
died. Irrigation  of  the  stomach  should  always  precede  the  admin- 
istration of  the  anesthetic,  as  evacuation  of  the  stomach,  by  prevent- 
ing vomiting,  will  guard  against  the  entrance  of  foreign  material  into 
the  larynx  and  trachea,  which  might  produce  asphyxia  during  the 
narcosis  or  pneumonia  later. 

Incision. — Differences  of  opinion  still  exist  among  surgeons  as 
to  the  size  and  location  of  the  abdominal  incision.  The  advocates 
of  eventration  argue  in  favor  of  a  long  incision  through  the  median 
line.  Kiimmell  advises  that  it  should  be  carried  from  the  ensiform 
cartilage  to  the  pubis,  for  the  purpose  of  affording  free  access  to 
every  part  of  the  abdominal  cavity ;  while,  on  the  other  hand,  a 
number  of  distinguished  surgeons,  among  them  Madelung,  Czerny, 
and  Obalinski,  are  in  favor  of  a  small  incision.  Polaillon  advocates 
lateral  incision  in  opening  the  abdomen  for  the  relief  of  intestinal 
obstruction  in  all  cases  where  the  seat  of  obstruction  can  be  reached 
more  directly  by  such  incision.  He  also  claims  that  in  cases  where 
extensive  meteorismus  is  present,  the  distended  intestines  are  more 
prone  to  prolapse  and  are  more  difficult  to  return  through  a  median 
than  through  a  lateral  incision.  He  thinks  that  this  is  due  to  a 
lesser  degree  of  intra-abdominal  pressure  in  the  iliac  than  the  middle 
abdominal  region,  and  that  in  the  former  the  muscular  fibers  keep 
the  margins  of  the  wound  in  contact.  He  opens  the  abdomen  in 
the  ilioinguinal  region  by  an  incision  parallel  with  the  fibers  of  the 
external  oblique  muscle,  and,  if  occasion  requires,  it  can  be  made 
sufficiently  large  to  permit  exploration  of  the  abdomen  by  the  intro- 
duction of  the  whole  hand.  In  lateral  laparotomy  exploration  is 
less  easy,  but  this  operation  is  indicated  in  all  cases  of  localized  ob- 
struction, circumscribed  adhesion,  or  when  any  symptoms  render  it 
probable  that  the  obstruction  exists  in  one  or  the  other  side  of  the 
abdominal  cavity.  In  case  a  distinct  swelling,  the  probable  seat  of 
the  obstruction,  can  be  detected  in  the  ileocecal  region,  the  ascend- 
ing or  descending  colon,  as  will  probably  be  the  case  in  ileocecal 
and  colic  invagination,  volvulus  of  the  sigmoid  flexure  and  tumors 
of  the  cecum  and  colon,  the  incision  should  be  made  over  the  most 
prominent  part  of  the  swelling,  as  such  a  course  affords  the  most 
ready  access  to  the  seat  of  obstruction  and  greatly  facilitates  the 
operative  procedures  that  may  become  necessary.  In  reference  to 
these  points  J.  Greig  Smith  regards  it  as  only  less  than  a  surgical 
calamity  to  perform  median  laparotomy  for  obstruction  in  the  colon, 
since  in  the  majority  of  cases  it  must,  he  says,  be  supplemented  by 
a  transverse  or  lumbar  incision.  In  making  a  lateral  incision  mus- 
cular fibers  must  be  respected,  and  whenever  the  size  of  the  incision 
permits,  the  knife  is  used  as  sparingly  as  possible,  substituting  mus- 
cle splitting  for  a  clean  incision. 

In  all  other  forms  of  intestinal  obstruction  and  in  all  cases  where 


INTRA-ABDOMINAL    EXAMINATION.  "jyj 

it  is  found  impossible  to  ascertain  the  nature  and  location  of  the 
obstruction,  the  incision  should  be  made  through  the  median  line. 
Not  much  time  should  be  consumed  in  making  the  external  incision. 
With  successive  strokes  of  a  sharp  scalpel  the  tissues  are  rapidly 
divided  until  the  subperitoneal  layer  of  fat  is  reached.  This  is  picked 
up  and  nipped  between  two  toothed  forceps  ;  when  the  peritoneum 
comes  into  view,  it  is  seized  and  divided  in  a  similar  manner.  The 
incision  is  then  enlarged  as  circumstances  may  require,  by  introduc- 
ing the  left  index-  and  middle  finger  into  the  peritoneal  cavity,  and 
dividing  the  tissues  with  a  blunt-pointed  bistoury  or  scalpel  between 
them.  Hemorrhage  is  arrested  as  it  occurs  by  appl\*ing  hemostatic 
forceps  to  the  bleeding  points,  which  in  most  instances  obviates  the 
application  of  ligatures.  In  reference  to  the  size  of  the  incision,  this 
will  vary  in  accordance  with  the  difficulties  that  are  encountered  in 
locating  the  seat  of  obstruction  and  in  removing  the  cause  or  causes 
that  have  produced  the  occlusion  ;  with  few,  if  any,  exceptions  it 
must  be  large  enough  to  admit  the  introduction  of  the  whole  hand. 
As  a  rule,  it  may  be  stated  that  the  ease  of  diagnosis  increases  with 
the  size  of  the  incision,  and  the  danger  that  attends  searching  in  the 
dark  for  the  seat  of  obstruction  more  than  overbalances  the  slight 
increase  of  risk  incident  to  a  large  incision.  Intra-abdominal  manual 
exploration  through  a  small  incision  is,  in  most  instances,  an  unre- 
liable diagnostic  measure,  as  the  cause  of  obstruction  may  be  of 
such  a  character  as  entirely  to  elude  such  method  of  examination. 
It  is  a  well-known  fact  that  the  location  of  the  seat  of  obstruction, 
even  in  the  postmortem  room  after  a  full  abdominal  section,  has 
sometimes  been  found  a  difficult  task.  A  large  incision  shortens 
the  operation  by  facilitating  the  intra-abdominal  examination,  and 
the  operative  treatment  of  the  obstruction  and  the  immediate  risks 
of  the  operation  are  diminished  in  proportion  to  the  shortening  of 
the  time  required  in  its  performance. 

Intra-abdominal  Examination. — The  first  and  most  important 
object  of  the  external  incision  is  to  enable  the  surgeon  to  make  a 
satisfactory  intra-abdominal  examination.  Unless  a  positive  diag- 
nosis has  been  made  beforehand,  the  first  incision  is  an  exploratory 
one.  Exploration  of  the  abdomen  for  the  purpose  of  locating  the 
obstruction  and  ascertaining  its  nature  is  a  more  difficult  procedure 
than  in  cases  of  abdominal  tumors,  and  on  this  account  the  first,  or 
exploratory,  incision  must  be  made  at  least  large  enough  to  enable 
the  surgeon  to  combine  ocular  inspection  with  manual  exj)loration. 

Smith  .says  :  "  The  best  guide  to  the  .seat  of  operation  is  not 
manual  exploration,  but  visual  examination,  assisted,  if  necessary,  by 
extrusion  of  bowel." 

The  surgeon  mu.st  bear  in  mind  tliat  in  nine  out  of  ten  cases  of 
intestinal  obstruction  the  cause  is  located  in  the  lower  portion  of  the 
abdominal  cavity,  below  the  umbilicus,  and  tiiat  in  the  great  majority 
of  the.se  cases  it  will  be  f<;und  in  either  the  right  or  left  inguinal 
region. 


7/8  ABDOMINAL    SECTION. 

Bryant  lays  down  the  rule  that  in  all  abdominal  operations  for 
intestinal  obstruction,  when  the  seat  of  obstruction  can  not  readily 
be  found,  the  surgeon  should  find  the  cecum,  since  it  will  prove 
to  be  his  best  guide.  If  this  be  distended,  he  will  at  once  know 
that  the  cause  of  obstruction  is  below  ;  if  it  be  found  collapsed  or 
not  tense,  the  obstruction  must  be  higher  up.  The  naked-eye  ap- 
pearances of  the  intestine  that  presents  itself  in  the  incision  will  serve 
a  useful  purpose  in  deciding  whether  it  belongs  to  the  part  of  intes- 
tine above  or  below  the  seat  of  obstruction.  In  all  cases  of  intes- 
tinal obstruction  the  bowel  above  the  seat  of  obstruction  is  dilated 
and  congested,  while  below  the  obstruction  it  is  empty,  pale,  and 
contracted  (Plate  5).  The  contents  of  the  presenting  loop,  if 
distended,  will  also  indicate  whether  it  is  near  or  distant  from  the 
obstruction  ;  if  near,  it  will  probably  contain  fluid  feces  and  gas  ;  if 
distant,  only  gas.  If  the  obstruction  is  located  in  the  lower  portion 
of  the  small  intestine  or  in  any  portion  of  the  colon,  without  ex- 
ception a  distended  loop  above  the  obstruction  presents  itself  in  the 
wound. 

Fowler  has  called  attention  to  the  fact  that  in  all  forms  of  intes- 
tinal obstruction  the  empty  contracted  portion  of  the  intestine  cor- 
responding to  the  part  below  the  obstruction  is  always  found  in  the 
pelvis,  and  that  it  may  be  most  easily  reached  toward  the  right  side. 
He  explains  this  on  the  supposition  that  during  the  violent  and  con- 
tinued peristalsis  and  gradual  distention  of  the  bowel  above  the 
obstruction  the  smaller  and  less  active  portion  of  bowel  below, 
after  expelling  its  contents,  is  forced  downward  into  the  pelvis,  while 
the  distended,  and  therefore  specifically  lighter,  portions  rise  to  the 
surface.  The  pelvis  also  is  too  small  to  hold  a  distended  loop. 
If  the  seat  of  obstruction  can  not  readily  be  found  by  man- 
ual exploration  of  the  regions  where  it  occurs  most  frequently, 
two  methods  of  further  examination  present  themselves  :  The  pre- 
senting bowel  is  drawn  forward  into  the  wound  and  systematically 
examined  step  by  step  as  it  glides  through  the  fingers  of  the  sur- 
geon, who  replaces  the  loops  as  they  are  examined.  This  method 
of  examination  is  safe  and  practicable  only  when  the  distention  of  the 
intestines  is  moderate  and  the  intra-abdominal  pressure  not  exten- 
sive, so  that  loop  after  loop  can  be  drawn  forward,  examined,  and 
returned  without  injury  to  the  intestine.  If  this  method  of  exam_in- 
ation  is  selected,  it  would  be  advisable  to  secure  the  portion  of 
intestine  first  examined  near  the  wound  by  passing  a  strip  of  gauze 
through  its  mesentery,  so  that  in  case  the  obstruction  is  not  found 
in  one  direction,  the  examination  in  the  opposite  direction  can  be 
made  without  passing  the  portion  already  examined  again  through  the 
operator's  hands.  MikuHcz  attains  the  same  object  by  an  assistant's 
holding  the  first  knuckle  that  appears  against  one  of  the  angles  of 
the  wound,  while  the  operator  examines  and  immediately  returns 
coil  after  coil  until  the  obstruction  is  found.  During  the  examin- 
ation prolapse  of  the  intestines  is  prevented  by  an  assistant,  who 


Plate  5. 


madelung's  method.  770 

guards  the  opening  with  an  aseptic  compress,  and  thus,  as  inspection 
IS  progressing,  unnecessary  exposure  of  the  intestines  is  prevented. 
For  the   purpose  of  avoiding   eventration   and   its   evil   conse- 
quences in  cases  of  intestinal  obstruction  with  great  distention  of  the 
abdomen.  Madelung  has  recently  described  a  new  method  of  dealing 
with  the   distended  intestines.      He  makes  a  comparatively  small 
incision   through  the   median   line,    and   brings  the  first  distended 
knuckle  of  intestine  that  presents  itself  into  the  wound,   and,   by 
passing  two  fixation  ligatures  through  the  mesentery  near  the  biwel 
and  making  traction  upon  them,   draws  it  forward  sufficiently  far 
until  both  limbs  of  the  loop   can   be  ligated  with  a  strip  of  aseptic 
gauze  at  a  point  corresponding  to  the  external  surface  of  the  wound 
The  patient  is  now  placed  on  his  side,   and  the  prolapsed  loop  is 
incised  over  the  convex  surface  and  its  contents  evacuated.      The 
gauze  ligature  is  slowly  loosened,   so  as  to  prevent  flooding  of  the 
wound  with  intestinal  contents   by   too  forcible  escape  of  the  fluid 
contents.      When  the  spontaneous  escape  ceases,  a  Nelaton  catheter 
IS  introduced  into  the  incised  bowel,   for  the  purpose  of  facilitating 
the    escape   of  intestinal   contents.      Fifteen    minutes    are  spent   in 
efforts  aimed  at  evacuation  of  the  distended  paretic  intestine,  during 
which  time  anesthesia  is  su.spended  in   order  to  effect  still'  further 
evacuation  of  the  bowel  above  the  seat  of  obstruction  by  the  con- 
traction of  the  abdominal  muscles.     After  all  discharge  has  ceased, 
the  visceral  wound  is  cleansed  and  sutured  and  the  ligatures  on  each 
side  of  the  wound  are  tied  so  as  to  prevent  undue  ten.sion  upon  the 
sutures  after  the  bowel   has  been   replaced.      The  ligatures  are  left 
hanging  out  of  the  wound,  to  serve  as  guides  to  the  incised  part  of 
the  bowel  after  the  completion  of  the  intra-abdominal  examination. 
The  abdominal  incision  is  now  enlarged,  the  intestine  drawn  forward, 
and  careful  search  made  for  the  obstruction.      If  tliis  is  not  found[ 
the  incised  loop  of  bowel  is  brought  into  the  wound,  the  sutures  of 
the  visceral  wound  and  the  two  ligatures  are  removed,  and  an  arti- 
ficial anus  is   established   by  stitching  the  intestinal   wound  to  the 
margins  of  the  external   wound,  suturing  the  portion   not  requireii 
for  this  purpose. 

While  Madelung's  procedure  cau  not  fail  in  facihtatiug  explora- 
tion of  the  abdomen  by  diminishing  intra-abdominal  pressure,  it  is 
questionable  if  the  room  tiius  gained  is  a  sufficient  recompcn.se  for 
the  time  lost  and  the  additional  risks  incident  to  an  intestinal 
wound  in  a  place  where  it  is  not  required.  If  a  laparotomy  is 
decided  upon  in  the  treatment  of  an  intestinal  obstruction,  it  is 
made  for  the  di.stinct  purpose  of  finding  and  removing  the  obstruc-. 
tion  ;  hence  if  the  patient's  strength  is  such  as  to  warrant  this 
treatment  at  all,  the  surgeon  should  not  clo.se  the  abdonun  with 
the  j)rincipal  object  of  the  operation  unaccomplished.  How  diffi- 
cult it  is  to  find  the  obstruction  in  .some  ca.ses  is  well  shown  by 
Madelung,  who,  in  .several  ca.ses  where  the  .seat  of  obstruction 
could  not  be  located  fitiring  life,  requested  the  [)alI)ol()gist  wlic.-n  he 


780  ABDOMINAL    SECTION. 

made  the  postmortems  to  locate  the  obstruction  by  introducing  his 
hand  through  an  incision,  allowing  him  from  ten  to  twenty  minutes 
for  the  exploration  ;  in  every  instance  he  failed  to  find  or  locate  the 
obstruction  within  the  specified  time.  When  the  ordinary  methods 
of  examination  through  an  incision  large  enough  to  permit  the 
introduction  of  the  hand  prove  inadequate  in  locating  the  obstruc- 
tion, after  a  search  of  from  ten  to  twenty  minutes  it  is  useless  and 
unwise  to  persist  in  pursuing  the  same  course.  Such  cases  should 
be  dealt  with  by  resorting  to  eventration.  This  method  of  ex- 
ploration was  first  suggested  by  Harber  in  1872,  and  practised  by 
Kiimmel  in  1885.  The  large  incision  that  he  advocates  is  neces- 
sarily followed  by  prolapse  of  the  distended  intestine,  and  enables 
the  surgeon  to  examine  rapidly  and  accurately  every  portion  of  the 
intestinal  canal,  with  a  view  to  locating  the  obstruction  with  little 
or  no  risk  of  inflicting  injury  during  the  examination.  The  great- 
est objection  that  has  been  urged  against  it  is  that  it  is  sometimes 
exceedingly  difficult  to  replace  the  intestines,  even  after  the  cause 
of  obstruction  has  been  removed,  as  the  paretic  intestines  are  slow 
in  regaining  their  normal  peristaltic  action,  and  that  during  the 
attempts  at  replacement  the  intestines  are  often  injured.  The 
proper  way  to  effect  replacement  is  to  follow  Kiimmell's  advice,  and 
instead  of  making  direct  compression,  to  resort  to  protection  of  the 
intestines  by  covering  the  Avhole  mass  with  a  warm  moist  aseptic 
compress,  the  margins  of  which  are  tucked  in  under  the  abdominal 
incision  ;  in  this  way  the  bowels  are  protected  against  the  injurious 
effects  of  irregular  direct  pressure,  and  are  guided  back  into  the 
abdominal  cavity  as  the  wound  is  closed  by  tying  the  sutures 
already  in  place  from  above  downward.  If  uniform,  diffuse,  gentle 
pressure  fails  in  replacing  the  intestines,  then  the  margins  of  the 
abdominal  incision  should  be  lifted  with  blunt  hooks,  an  expedient 
that  renders  material  aid  in  effecting  replacement.  I  have  found,  in 
a  number  of  cases,  that  partial  inversion  of  the  body  is  a  material 
aid  in  effecting  reduction  of  the  prolapsed  intestines.  Should  the 
obstacles  be  so  great  as  to  frustrate  all  attempts  at  replacement,  it 
is  better  to  resort  to  incision  and  evacuation  of  the  most  distended 
portion  of  the  prolapsed  bowel,  which  can  be  done  with  greater 
safety  and  more  marked  effect  than  by  the  plan  devised  by  Made- 
lung.  An  overdistended  paretic  intestine  is  always  a  source  of 
danger  in  the  abdominal  cavity.  An  intestinal  wall  in  such  a  con- 
dition is  permeable  to  pathogenic  microbes.  Unloading  of  its  con- 
tents relieves  tension,  removes  preformed  toxins  and  pathogenic  mi- 
crobes, and  is  best  calculated  to  restore  peristaltic  action.  Greig  Smith 
strongly  advocated  operative  evacuations  of  intestinal  contents  in 
cases  of  obstruction  where  distention  is  a  marked  feature.  Mere 
overdistention  of  the  intestinal  walls  is  a  potent  factor  in  the  pro- 
duction of  obstruction  ;  physical  and  physiologic  causes  combine  to 
render  an  overdistended  bowel  incapable  of  propelling  its  contents. 
The  operation  is  not  complete  unless  this  condition  be  corrected. 


TREATMENT    OF    DISTENDED    INTESTINE.  78 1 

According  to  the  nature  of  the  case,  Smith  pointed  out  that  the 
measures  adopted  should  be  one  of  the  following  : 

(i)  Simple  evacuation  of  contents  with  immediate  suturing  and 
reduction  of  the  bowel.  (2)  Evacuation  with  drainage  for  several 
hours  or  days,  and  subsequent  closure  and  return  of  the  loop.  (3) 
Evacuation  with  permanent  drainage. 

In  peritonitis,  attended  as  it  usually  is  by  dynamic  obstruction, 
Mixter  recommended,  a  number  of  years  ago,  free  incision  and 
evacuation  of  the  overdistended  intestine.  He  recommends  that 
the  distended  intestines  be  drawn  out  of  the  wound,  held  over  a 
basin,  incised  in  from  one  to  four  places,  and  thoroughly  emptied, 
after  which  they  should  be  quickly  washed  off  with  hot  saline  solu- 
tion, sutured,  and  returned,  and  the  abdominal  incision  closed.  He 
has  made  use  of  this  method  in  nearly  twenty  cases,  a  number  of 
which  recovered,  and  in  those  that  died  the  wounds  were  found 
impermeable  to  air  and  fluids. 

McCosh  has  found,  from  his  experience,  that  after  evacuation  of 
the  intestine  by  incision,  injection  of  a  saturated  solution  of  sulphate 
of  magnesia  has  a  decided  effect  in  restoring  peristalsis  and  in 
diminishing  the  mortality  of  the  operation.  At  least  from  six  to 
eight  feet  of  intestine  can  be  evacuated  through  a  single  incision  by 
pouring  out  its  contents.  In  doing  so  the  intestine  below  and  above 
the  incision  is  elevated,  and  the  contents  are  poured  out  from  each 
side.  If  the  intestine  is  distended  for  a  greater  distance,  two  or 
more  incisions  must  be  made.  The  visceral  incision  should  always 
be  transverse  and  at  least  an  inch  in  length,  and  at  a  point  directly 
opposite  the  mesenteric  attachment.  The  wound  is  sewed  by  one 
row  of  Lembert  sutures  placed  closely  together.  The  practice  of 
McCosh  of  injecting  into  the  intestine  from  one  to  four  drams  of 
magnesium  sulphate  in  concentrated  solution  will  prove  as  effective 
in  restoring  peristalsis  of  the  intestine  made  paretic  from  obstruc- 
tion as  in  cases  of  overdistention  of  the  bowel  from  dynamic  causes. 

The  value  of  free  evacuation  of  the  overdistended  obstructed 
bowel  is  well  shown  by  a  case  that  recently  came  under  my  observa- 
tion. The  patient  was  a  woman  forty-eight  )'ears  of  age,  the  mother 
of  eight  children,  the  last  being  an  infant  ten  months  old.  She  stateti 
that  she  had  suffered  during  the  last  year  from  con.stipation,  but  had 
always  been  promptly  relieved  by  cathartics.  Ten  days  before  her 
admission  into  the  hosj^ital  symptoms  of  acute  intestinal  obstruction 
appeared,  which  increa.sed  in  intensity  until  fecal  vomiting  super- 
vened the  day  before  she  entered  the  hospital.  .She  had  been 
treated  by  high  injections  and  irrigation  of  the  stomach — the  former 
had  no  effect,  but  the  latter  afforded  great  relief.  The  patient  was 
well  nourished,  and  her  general  a[)|)earancc  gave  rise  to  no  suspi- 
cion of  malignant  disease  in  any  of  the  organs.  She  had  passed 
nothing  by  the  rectum  .since  she  was  taken  ill,  and  the  retching  and 
vomiting  were  persi.stent.  The  abdomen  was  uniformly  and  enor- 
mously distended;   upon  the  surface  of  the  abdominal  wall  the  out- 


782  ABDOMINAL   SECTION. 

lines  of  some  distended  coils  of  intestine  could  be  distinctly  seen. 
The  tympanitic  distention  of  the  abdomen  interfered  with  respira- 
tion, the  respiratory  movements  being  shallow  and  rapid,  the  lips 
cyanosed,  and  the  extremities  cold.  Examination  per  vaginam  and 
rectum  revealed  nothing  as  to  the  seat  and  nature  of  the  obstruc- 
tion. Percussion  and  palpation  of  the  abdomen  yielded  the  same 
negative  results.  Laparotomy  was  performed  under  the  most  care- 
ful aseptic  precautions.  The  stomach  was  irrigated,  and  chloroform 
was  used  as  an  anesthetic.  The  operation  was  performed  with  the 
patient  upon  a  rubber  bed  filled  with  hot  water.  The  first  incision 
was  made  half-way  between  the  umbilicus  and  pubes,  and  large 
enough  to  permit  the  introduction  of  the  hand.  As  soon  as  the 
peritoneal  cavity  was  opened  a  loop  of  small  intestine,  distended  to 
three  times  its  natural  size  and  intensely  congested,  presented  itself. 
This  was  pushed  aside,  and  similar  loops  made  their  appearance. 
The  hand  was  then  introduced,  and  it  was  found  that  the  cecum  and 
entire  colon  were  also  enormously  distended,  which  proved  that  the 
obstruction  was  located  low  down  in  the  colon  or  in  the  upper  part 
of  the  rectum  ;  but  the  most  careful  attempts  by  manual  explora- 
tion failed  in  furnishing  any  clue  as  to  the  location  or  nature  of  the 
obstruction.  The  incision  was  enlarged  upward  an  inch  above  the 
umbilicus  and  downward  to  the  pubes,  for  the  purpose  of  effecting 
complete  eventration.  Two  assistants  caught  the  intestines  in 
warm  moist  aseptic  compresses  as  they  prolapsed,  and  as  tiie  abdom- 
inal cavity  was  nearly  empty,  it  was  possible  to  explore  with  ease 
the  sigmoid  flexure,  where  was  found  the  seat  of  the  obstruction. 
The  carcinomatous  obstruction  was  finally  located  at  the  junction 
of  the  colon  with  the  rectum.  As  resection  in  this  locality  was 
impossible,  and  for  the  same  anatomic  reasons  an  anastomosis  could 
likewise  not  be  made,  it  became  necessary  to  establish  an  artificial 
anus  in  the  left  groin.  The  sigmoid  flexure  was  pushed  into  an 
inguinal  incision  and  sutured  in  position.  Reposition  of  the  dis- 
tended intestines  by  the  ordinary  methods  failed.  The  patient  was 
now  placed  on  her  side,  and  one  of  the  most  distended  loops  was 
grasped,  held  over  a  basin,  and  punctured  with  a  trocar,  while  the 
remaining  intestines  remained  covered  with  the  warm  compresses. 
As  the  escape  of  gas  and  fluid  feces  through  the  cannula  was  very 
slow,  transverse  incision  an  inch  and  a  half  in  length  was  made  in 
the  paretic  distended  intestine.  As  the  bowel  did  not  contract,  the 
escape  of  contents  was  very  slow,  and  it  became  necessary  to 
resort  to  pouring  out  of  the  contents,  as  it  were,  by  seizing  the 
bowel  several  feet  above  and  below  the  incision  and  elevating  it,  a 
large  quantity  of  fluid  feces  being  literally  thus  poured  out.  When 
no  further  evacuation  could  be  effected,  the  visceral  wound  was 
closed  by  the  continuous  suture,  and  after  the  loop  was  thoroughly 
disinfected,  the  bowels  were  returned  without  further  difficulty. 
The  abdominal  incision  was  closed  in  the  usual  way,  only  that  two 
tension  sutures  were  added  as  a  matter  of  precaution.     After  the 


OPERATIVE    TREATMENT    OF    THE    OBSTRUCTION.  783 

abdominal  wound  was  closed  and  dressed,  the  colon,  which  had  been 
stitched  into  the  inguinal  wound,  was  incised,  and  the  margins  of  the 
incision  were  separately  stitched  to  the  sides  of  the  external  wound. 
A  considerable  quantity  of  gas  and  fluid  feces  escaped.  The  vom- 
iting ceased  after  the  operation,  and  the  patient  rallied  under  the 
effects  of  stimulants.  The  abdominal  distention  had  diminished 
greatly  the  next  day,  and  disappeared  almost  completely  on  the 
second  day.  The  patient's  general  condition  continued  to  improve 
until  the  tenth  day  after  the  operation,  when  symptoms  of  collapse 
set  in,  which  persisted  until  she  died  on  the  following  day.  The 
postmortem  showed  that  the  median  incision  had  healed  with  the 
exception  of  the  skin,  and  that  the  artificial  anus  had  served  as  a 
perfect  outlet  for  the  intestinal  contents.  The  small  intestine  was 
restored  to  its  normal  size,  the  incision  had  healed,  the  fine  silk 
suture  being  completely  embedded.  The  cause  of  the  recent  dif- 
fuse septic  peritonitis  was  traced  to  perforation  of  a  small  abscess 
behind  the  carcinoma.  The  constriction  caused  by  the  carcinoma 
had  reduced  the  lumen  of  the  bowel  so  much  that  it  was  permeable 
only  to  the  tip  of  the  little  finger. 

Reference  will  again  be  made  to  the  subject  of  chronic  cau.ses 
giving  rise  to  acute  obstruction.  This  case  also  illustrates  the  im- 
portance of  establishing  the  artificial  anus,  when  such  a  procedure 
can  not  be  avoided,  not  in  the  laparotomy  wound,  but  in  the  right 
or  left  inguinal  region.  When  eventration  is  practised,  it  is  essen- 
tial to  furnish  the  prolapsed  and  dilated  intestine  with  an  artificial 
covering  that  should  act  as  nearly  as  possible  as  a  substitute  for 
the  abdominal  parietes.  This  is  best  accomplished  with  warm 
compresses  wrung  out  of  a  hot  saline  solution  in  the  hands  of  one 
or  two  reliable  assistants.  After  the  surgeon  has  found  the  obstruc- 
tion, it  becomes  necessary  to  demonstrate  the  permeability  of  the 
remaining  portion  of  the  intestinal  canal,  as  it  has  happened  that 
after  a  successful  removal  of  an  obstruction  patients  have  died 
because  a  second  obstruction  was  overlooked.  Of  course,  in  such 
cases  the  search  for  additional  obstructions  must  be  extended  below 
the  obstruction,  which  has  been  found  and  removed.  A  valuable 
te.st  for  ascertaining  the  permeability  of  the  remaining  portion  of 
the  intestinal  canal  is  furnished  by  rectal  insufflation  of  hydrogen 
gas  or  air.  In  cases  where,  after  eventration,  it  is  not  possible  to 
find  the  obstruction  by  examination  of  the  distended  portion  of  the 
intestine,  the  contracted  empty  portion  below  the  obstruction  can  be 
brought  into  sight  bv  the  same  means,  and  a  .search  for  the  ob.struc- 
tion  made  from  below  upward  by  examining  the  bowel  as  it  becomes 
inflated  until  the  scat  of  obstruction  is  reached. 

OPERATIVE  TREATMENT  OF  THE  OBSTRUCTION. 
Intestinal  Anastomosis. — The  results  of  j:)ostmortem  examin- 
ations and  clinical  (.xperience  have  shown  how  difficult  it  is  in  many 
ca.ses  to  find  the  obstruction,  and  this  is  more  especially  the  ra.se  wiicn 


784 


ABDOMINAL    SECTION. 


the  general  condition  of  the  patient  is  such  as  to  forbid  free  eviscer- 
ation. 

What  shall  be  done  if  the  obstruction  can  not  be  found  after  all 
diagnostic  resources  have  been  exhausted  ?  Shall  we  establish  an 
artificial  anus  and  leave  the  patient  to  the  inevitable  fate  of  remain- 
ing a  sufferer  from  this  loathsome  condition  the  remainder  of  his  life- 
time should  he  recover  from  the  operation  ?  Under  such  circum- 
stances the  surgeon  assumes  a  great  responsibility  in  establishing 
an  artificial  anus  high  up  in  the  intestinal  canal,  even  as  far  as  the 
immediate  effects  of  the  operation  are  concerned.  The  paretic 
bowel  below  the  seat  of  the  artificial  outlet  unable  to  empty  itself 
of  its  contents  constitutes  an  immediate  and  remote  source  of 
danger,  as  it  leaves  that  portion  of  the  bowel  between  the  new 
opening  and  the  obstruction  in  the  same  condition  as  before  the 
operation,  and  permanent  exclusion  of  a  considerable  portion  of  the 
intestinal  canal  alone  may  subsequently  destroy 
life  by  progressive  marasmus.  In  such  cases  I 
should  advise  the  following  plan  of  treatment : 
The  empty  bowel  below  the  seat  of  obstruction, 
if  not  already  found,  should  be  inflated  per  rec- 
tum with  hydrogen  gas  or  air,  the  highest  por- 
tion of  the  inflated  bowel  drawn  forward  into  the 
wound,  and  two  rubber  bands  passed  through 
its  mesentery,  about  four  inches  apart,  and  held 
in  place  by  an  assistant.  The  surgeon  now 
locates,  as  near  as  he  can,  the  lowest  portion 
of  the  bowel  on  the  obstructed  side,  which  is 
also  brought  forward  into  the  wound  and  simi- 
larly secured.  The  bowel  on  the  proximal 
side  is  incised  on  the  convex  surface  to  the 
extent  of  an  inch  and  a  half;  through  this  in- 
cision the  contents  are  evacuated  as  far  as 
possible,  after  which  all  four  rubber  bands 
and  the  bowel   on  the  distal   side  is  incised   in  a  similar 


Fig.  484. — Senn's 
decalcified  perforated 
bone-plate  for  anasto- 
mosis. 


are  tied, 
manner. 

The  continuity  of  the  intestinal  canal  is  then  restored  by  uniting 
the  two  visceral  wounds  by  the  use  of  Murphy's,  Ramonge's,  or 
Frank's  anastomosis  button,  absorbable  bone-plates  or  vegetable 
discs,  or,  what  will  be  the  most  common  practice  of  the  future,  by 
suturing.  If  the  anastomosis  is  made  by  approximation  plates,  the 
wounds  are  enlarged  to  the  requisite  extent  and  one  of  the  plates 
is  inserted  into  each,  and  with  a  round  needle  the  margin  of  the 
wound  on  each  side  is  transfixed  with  a  lateral  suture.  After  the 
plates  and  sutures  are  in  place,  the  loops  are  thoroughly  disinfected, 
and  the  serous  surfaces,  to  the  extent  of  the  size  of  the  plates,  are 
lightly  scarified  with  the  point  of  a  needle,  when  the  wounds  are 
placed  vis  a  vis,  and  the  corresponding  four  threads  tied  together 
with  sufficient  firmness  to  secure  perfect  coaptation  of  the   serous 


OPERATIVE    TREATMENT    OF    THE    OBSTRUCTION. 


785 


surfaces.  The  sutures  are  cut  short,  and  their  ends  buried  as  deeply 
as  possible  by  pushing  them  in  between  the  approximated  surfaces 
with  a  director  or  blunt  scissors.  A  few  superficial  stitches  of  a 
continued  suture  will  enhance  the  safety  of  the  operation.  In  this 
manner  an  anastomosis  is  established,  with  the  exclusion  of  prob- 
ably only  a  small  portion  of  the  intestinal  tract. 

After  uniting  two  intestines  by  approximation  plates  in  the 
formation  of  an  intestinal  anastomosis,  it  appears  at  first  sight  as 
though,  on  the  slightest  distention  of  the  intestines,  leakage  of  gas 
or  fluid  contents  would  take 
place  between  the  serous 
surfaces.  That  this  fear  is 
unfounded  has  been  proved 
satisfactorily  by  a  number 
of  experiments.  The  in- 
testines of  animals  recently 
killed  were  used,  and  an 
anastomosis  was  made  be- 
tween the  lower  portion  of 
the  ileum  and  the  colon. 
The  colon  was  tied  below 
the  new  opening,  and  fluid 
forced  into  the  ileum  on 
the  proximal  side.  The 
pressure  was  measured  by 
a  mercury  gage.  It  was 
found  that  no  leakage  oc- 
curred under  a  pressure  of 
two  pounds  to  the  square 
inch  continued  for  thirty 
seconds.  As  even  in  cases 
of  great  intestinal  disten- 
tion the  pressure  can  never 
reach  this  degree,  leakage 
from  mechanical  or  phy.si- 
cal  causes  will  never  take 
place  from  the  new  opening. 
The  margins  of  the  visceral 
wounds  act  like  valves,  and 

when  the  serous  surfaces  arc  kept  in  contact  by  the  plates,  jire- 
vent  the  escape  of  gas  or  fluids  into  the  peritoneal  cavity.  The 
.safety  and  practicability  of  this  operation  has  been  abundantly 
demon.stratcd  by  experiments  on  animals  and  by  a  number  of  oper- 
ations on  the  human  subject.  The  operative  treatment  of  the 
obstruction  will  depend  up(;n  the  location,  e.xtent,  and  nature  of  the 
cause.  If  it  is  decided  not  to  rcmtn'e  the  obstruction,  either  on 
account  of  its  intrinsic  harmless  character,  aside  from  its  mechanical 
effect,  or  on  account  of  its  extent,  in  which  case  tl)e  removal  would 

so 


Fig.  485. — Ileocolostomy  wilh  decalcified 
bone-plates,  showing  plates  in  position,  one  in  the 
ileum,  the  other  in  the  colon  :  u,  a,  a.  Lateral  or 
fixation  sutures  passed  through  the  margins  of  the 
wound,  a  to  be  tied  to  a  ;  />,  b,  b' ,  b' ,  end  or  appo- 
sition sutures  to  be  tied,  b  to  b  and  b'  to  b' ;  c, 
posterior  or  seromuscular  sutures  (Keen  and 
White). 


786 


ABDOMINAL    SECTION. 


be  an  imminent  source  of  danger  to  life,  or  if,  after  removal,  a  recur- 
rence in  the  near  future  appears  inevitable,  an  anastomosis  is  estab- 
lished between  the  intestine  above  and  below  the  obstruction  by 
lateral  apposition  with  decalcified  perforated  bone-plates.  By  this 
operation  the  continuity  of  the  intestinal  canal  is  restored,  with  per- 
manent exclusion  of  the  seat  of  obstruction.  In  cases  of  multiple 
cicatricial  stenoses  as  a  cause  of  obstruction,  intestinal  anastomosis, 
for  instance,  would  be  a  vastly  more  safe  operation  than  resection 
and  circular  enterorrhaphy,  and  would  secure  equally  well  the 
restoration  of  the  continuity  of  the  intestinal  canal.  In  cases  of 
carcinoma  of  the  intestine  with  extensive  infiltration  of  the  lymphatic 
glands,  a  resection,  followed  by  circular  enterorrhaphy,  must  always 
constitute  a  hazardous  procedure,  and  even  if  it  proved  successful, 
an  early  recurrence  of  the   disease  would  be    inevitable.      Under 


Fig.  486. — Showing  the  anterior  continued  seromuscular  suture  as  the  final  step  in  ileo- 
colostomy  (Keen  and  White). 

such  circumstances  it  is  advisable  to  establish,  in  preference,  an  intes- 
tinal anastomosis  that  will  effectually  exclude  the  cause  of  obstruc- 
tion, alleviate  suffering,  and  prolong  life. 

The  opponents  of  laparotomy  in  cases  of  acute  intestinal 
obstruction  have  urged  as  one  of  the  principal  reasons  for  their 
opposition  that  the  dilated  inflamed  intestine  above  the  obstruction 
is  not  in  a  condition  to  undergo  reparative  processes  when  the 
operation  demands  a  solution  of  continuity  in  this  part  of  the  intes- 
tinal tract.  Circular  enterorrhaphy  under  such  circumstances  is  a 
very  dangerous  procedure  for  two  reasons:  (i)  It  becomes  neces- 
sary to  unite  bowel  ends  of  unequal  size.  (2)  The  inflamed  intes- 
tine has  undergone  textural  changes  ill  adapted  for  suturing,  as  the 
sutures  readily  cut  through  the  softened  tissues.  A  number  of 
clinical  observations  have  shown  that  the  failures  that  have  at- 
tended circular  enterorrhaphy  in  such  cases  are  not  due  to  a  lack 
of  healing  capacity  on  the  part  of  the  inflamed  end   of  the  bowel, 


OPERATIVE    TREATMENT    OF    THE    OBSTRUCTION. 


7^7 


but  to  the  mechanical  difficulties  that  are  encountered  in  the  ap- 
proximation and  retention  of  the  bowel  ends,  and  the  danger  of  the 
cutting  through  or  yielding  of  the  sutures.  It  can  be  stated,  on 
the  contrar}',  that  in  case  septic  peritonitis  does  not  exist,  the  vas- 
cularity of  the  bowel  above  the  seat  of  obstruction  constitutes  a 
favorable  condition  for  rapid  union.  To 
demonstrate  the  correctness  of  this  asser- 
tion I  made  the  following  experiments  : 

ExPERiMKNi"  I. — Dog,  weight  fourteen  pounds. 
The  whole  abdomen  was  shaved  and  thoroughly  disin- 
fected, and  while  the  animal  was  under  the  influence  of 
ether  a  small  incision  was  made  in  the  left  iliac  region, 
and  a  loop  of  intestine  drawn  forward  and  ligated  with 
a  hand  of  iodoform  gauze,  the  ligature  being  tied  with 
sufficient  firmness  to  cause  complete  occlusion ;  the 
intestine  was  then  returned  and  the  wound  sutured. 
Seventy- three  hours  later  the  dog  was  again  etherized 
and  median  laparotomy  performed.  Distended  vasculai 
loops  of  the  intestine  came  into  the  wound,  which  were 
pushed  aside  and  the  hand  introduced,  which,  being 
passed  toward  the  left  inguinal  region,  at  once  came  in 
contact  with  the  ligated  portion,  which  had  formed 
adhesions  to  the  parietal  peritoneum  and  neighboring 
intestinal  loops.  The  adhesions  were  separated,  and 
the  ligated  loop  was  drawn  out  of  the  wound.  Above 
the  ligature  the  bowel  was  at  least  one  and  a  half  times 
larger  than  immediately  below  the  seat  of  obstruction, 
very  vascular,  and  contained  gas  and  fluid  feces.  The 
degree  of  dilation  diminished  from  below  upward.  The 
seat  of  obstruction  was  eight  inches  above  the  ileocecal 
valve,  and  the  gauze  ligature  was  covered  with  a  thick 
layer  of  plastic  lymph.  The  obstruction  was  left,  and 
the  continuity  oi^  the  intestinal  canal  restored  by  an 
ileocolostomy  with  perforated  decalcified  bone-plates. 
The  animal,  which  was  not  vigorous  before  the  experi- 
ment was  made,  apjieared  much  prostrated  and  died 
twenty-four  hours  after  the  operation.  The  necropsy 
showed  that  the  bowel  above  the  constriction  had  to  a 
great  extent  recovered  its  normal  size  and  color.  The 
two  intestines  where  anastomosis  was  made  were  firmly 
adherent,  the  groove  between  them  corresponding  to  the 
length  of  the  ])lates  filled  in  with  ])laslic  lymph.  The 
new  opening  was  permeable.  No  leakage  occurred  at 
ix)int  of  operation  under  hydrostatic  pressure  and  no 
peritonitis. 

ElxPERlMKST  2. — Dog,  weight  twenty  four  ijounds. 
Obstruction  was  produced  in  a  similar  manner  as  in  pre- 
ceding experiment.  Seventy-five  hours  later  operative 
treatment  of  obstruction  %  laparotomy    was  instituted. 


Fig. 
lomosis 
plates ; 


487. — Lateral  anas- 
in  dog,  with  Scnn's 
sixty-three  days. 
The  arrow  indicates  the  di- 
rection of  the  flow  through 
the  bowel.  It  will  be  noticed 
that  the  anastomosis  still  re- 
mains lateral.  One  blind 
end— that  of  the  upper  bowel 
— has  contracted  more  than 
the  other  (two-thirds  size) 
(after  lulmunds  and  Hal- 
lance). 


The  seat  of  obstruction  was  again  readily  found  by 
manual  exploration  of  the  abdomen.  The  bowel  above  seat  of  constriction  was  al 
least  twice  the  normal  size  and  highly  congested.  Peristaltic  action  sluggish,  respond- 
ing very  slowly  and  imperfectly  to  mechanical  irritation.  (Jauze  band  buried  under  a 
ring  of  plastic' Ivmph,  which,  bridge  like,  united  the  bowel  below  and  above  the  con- 
striction. As  the  obstruction  was  located  about  the  middle  of  the  ileum,  an  ileoiltoslomy 
by  lateral  ap|K)silion  with  decalcified  perforated  bone  plates  was  made,  having  the  gauze 
band  undisturbed.  The  incision  into  ihe  bowel  above  the  seal  of  ..bsirnrti<.n  showed  that 
all  the  coats  were  thickened  and  soflen.d.  while  below  the  obslruclion  only  the  mucous 
membrane  was  in  a  state  of  catarrhal  inflaniniation.  About  eight  inches  of  the  bowel, 
including  the  seat  of  constriction,  were  excluded  by  tli<-  operation.  The  animal  sh.iwed 
no  signs  of  suffering  or  illness  after  the  oiieration,  an<l  when  kille.l,  after  the  ex|Mralion  of 
twenty-one  days,  was  in  excellent  condition.      Duiing  this  time  the  a|.|)elite  was  good 


788 


ABDOMINAL   SECTION. 


and  fecal  evacuations  were  normal.  Gauze  band  was  completely  encapsulated,  and  close 
to  it  was  an  acute  flexion  of  the  bowel  ;  excluded  portions  were  adherent  to  each  other 
along  convex  surface  ;  bowel  above  constriction  was  about  one-third  larger  than  below. 
New  openings  admitted  the  tips  of  two  fingers. 

Experiment  3. — Dog,  weight  twenty-eight  pounds.  Laparotomy  performed  seven 
days  after  complete  obstruction  had  been  caused  by  ligation  of  small  intestine  with  gauze 
band  through  a  small  wound  in  the  left  inguinal  region.  Moderate  tympanites  present. 
Obstruction  was  found  sixteen  inches  above  the  ileocecal  region.  Peristaltic  action  was 
almost  suspended  in  bowel  above  obstruction — normal  below.  The  intestine  above  the 
constriction  was  dilated  to  twice  its  normal  size,  exceedingly  vascular,  containing  solid 
fecal  masses,  fluid  feces,  and  gas  ;  below,  empty,  contracted,  and  anemic.  Exclusion  of 
six  inches  of  the  intestine  at  seat  of  obstruction  and  restoration  of  continuity  of  intestinal 
canal  by  ileoileostomy  with  decalcified  perforated  bone-plates.  After  operation  the  func- 
tion of  the  intestinal  canal  was  normal  and  the  appetite  good.  The  animal  was  killed 
eight  days  after  operation.  No  peritonitis  occurred  ;  there  was  adhesion  of  omentum  to 
the  line  of  abdominal  incision.  Gauze  band  was  completely  covered  by  a  plastic  exuda- 
tion, and  there  were  a  number  of  adhesions  between  adjacent  intestinal  loops.  Point  of 
operation  was  situated  in  the  center  of  a  horseshoe-shaped  loop  of  intestine,  which  was 
found  to  be  the  excluded  portion.  Intestine  above  obstruction  was  about  one-fourth  larger 
in  size  than  below.  Excluded  portion  of  bowel  was  empty.  At  seat  of  anastomosis  a  mass 
of  straw  and  hair  had  accumulated  on  proximal  side.  New  opening  was  large  enough  to 
admit  two  fingers. 

Experiment  4. — Dog,  weight  thirty-four  pounds.  There  was  complete  obstruction 
of  small  intestines  by  ligation  with  gauze  band  through  a  small  wound  in  the  left  iliac 

region.  Operative 

yy   .     ^^  treatment    by    lapar- 

otomy instituted  one 
hundred  and  twenty 
hours  later.  This 
animal  vomited  sev- 
eral times  shortly 
before  the  operation. 
Bowel  at  seat  of  ob- 
struction was  adher- 
ent to  adjacent  intes- 
tines. Obstruction 
was  readily  found 
and  brought  into  the 
incision.  Intestine 
above  constriction 
was  twice  its  normal 
size,  dark  purple  in 
color,  and  the  tissues 
were  swollen  and 
very  much  softened.  Below  constriction  the  bowel  was  empty,  collapsed,  pale,  and  only 
the  mucous  membrane  was  in  a  state  of  catarrhal  inflammation.  The  dilated  bowel  con- 
tained gas  and  fluid  feces.  Peristaltic  action  in  this  part  was  nearly  suspended,  the 
response  to  mechanical  irritation  being  slow  and  imperfect.  Below  the  obstruction  the 
function  of  bowel  remained  unimpaired.  As  the  occlusion  was  only  four  inches  above 
the  ileocecal  valve,  it  was  found  impossible  to  limit  the  anastomosis  to  the  ileum,  con- 
sequently the  continuity  of  the  bowel  was  restored  by  an  ileocolostomy,  uniting  the  ileum 
just  above  the  obsti-uction  with  the  colon  above  the  cecum,  using  the  perforated  approxi- 
mation plates.  The  gauze  band  was  left  in  situ.  The  animal  showed  no  untoward 
symptoms  after  the  operation,  and  was  killed  twenty-one  days  later.  During  this  time 
appetite  was  good  and  intestinal  function  normal.  A  number  of  adhesions  were  found 
at  site  of  operation  between  adjacent  intestinal  loops.  Gauze  band  was  completely 
encysted.  Some  crude  material,  as  straw,  hair,  and  fragments  of  bone,  was  found  on 
the  proximal  side  of  new  opening.  Anastomotic  opening  was  large  enough  to  admit  tips 
of  two  fingers  ;  union  between  approximated  portions  of  intestine  was  so  complete  that  it 
presented  all  around  the  appearance  as  though  their  peritoneal  surfaces  were  continuous. 

These  experiments  show  conclusively  that  in  acute  obstruction, 
even  after  seven  days,  the  bowel  above  the  obstruction  is  capable  of 
undergoing  a  rapid  reparative  process,  and  that  adhesive  union  takes 
place  as  early  as,  if  not  earlier  than,  in  operations  upon  a  normal 


Fig.  488. — Lateral  anastomosis  as  a  substitute  for  circular  enter- 
orrhaphy  after  enterectomy  (after  Baracz). 


OPERATIVE    TREATMENT    OF    THE    OBSTRUCTION. 


789 


intestine.  The  experiments  likewise  prove  the  greater  safety  of 
anastomosis  by  lateral  apposition  with  decalcified  perforated  bone- 
plates  than  of  resection  and  circular  enterorrhaphy  in  restoring  the 
continuity  of  the  in- 
testinal canal.  Anas- 
tomosis after  resec- 
tion of  intestinal  ob- 
struction can  be  made 
in  the  same  manner 
between  the  proximal 
and  distal  parts  after 
the  resected  ends  have 
been  closed  by  in- 
vagination and  a  few 
stitches  of  the  con- 
tinued suture,  as 
when  the  obstruction 
is  not  resected,  but 
excluded. 

In  cases  of  con- 
genital atresia  of  the 
small  intestine,  most 
frequently  met  with 
in  the  upper  portion, 
anastomosis    should 

always  take  the  place  of  circular  resection,  as  the  operation  can  be 
done  in  less  than  twenty  minutes,  an  exceedingly  important  matter 
as  far  as  the  immediate  effects  of  the  operation  are  concerned  in 
infants,  at  the  most  only  a  few  days  old.  In  cases  where  such  a 
congenital   defect  is  suspected,  the   abdomen   should  be  ojjcncd  in 

the  median  line,  l)e- 
ing  careful  not  to  cut 
through  the  umbili- 
cus, when  the  seat  of 
obstruction  can  be 
readily  and  rapidly 
located  by  inflation 
of  the  stomach  and 
rectum  with  hydro- 
gen gas  or  air.  It  is 
necessary  to  inflate 
from  both  directions, 
as  in  some  cases  the 
atresia  is  multiple. 
The  anastomosis 
button  of  Murphy  has  had  an  extensive  trial  as  a  substitute  for 
suturing  in  performing  gastro-enterostomy  and  intestinal  anasto- 
mosis, and   many  surgeons  of  large  experience  speak  of  it   in    the 


Fig.   489. — Intestinal  anastomosis  for  congenital  atresia 
of  ileum.      Ileosigmoidostomy  (after  Wanitscheck). 


U^ 


Fig.  490. — Murphy's  oblong  anastomosis  button 
A,  Closed  ;   15,  open. 


790 


ABDOMINAL    SECTION. 


highest  terms.  Czerny,  who  has  had  an  enormous  experience  in 
suturing,  recommends  it  very  highly  and  has  used  it  with  excellent 
success  on  a  large  scale.      The  surgeon  who  intends  to   make  use 

of  it  should  supply  himself 
with  a  full  set,  and  should 
use  only  buttons  of  faultless 
make.  Half  of  the  button 
is  inserted  into  each  opening, 
and  fixed  in  place  by  purse- 
string  suture.  After  uniting 
the  two  halves,  on  joining 
the  wounds  the  serous  sur- 
faces over  the  margin  of  the 
button  should  be  united  by 
the  continued  suture  of  fine 
silk  as  an  additional  security. 
Two  objections  present 
themselves  against  the  gen- 
eral adoption  of  the  button 
as  a  substitute  for  suturing 
— viz.:  (i)  The  danger  aris- 
ing from  the  button  failing  to  pass  the  intestinal  canal,  remaining 
as  a  source  of  irritation  or  possibly  acting  later  as  a  mechanical 
cause  of  obstruction.  (2)  The  limited  inclusion  of  the  margins  of 
the  viscera]  wounds  between  the  two  halves  of  the  button  and  the 
pressure  necessary  to  keep  them  in  contact  always  give  rise  to  mar- 
ginal sloughing  and  occasionally  to  perforation.  The  danger  from 
the  latter  source  is  always  greater  in  uniting  diseased  than  healthy 
intestine.      The  risks  just  alluded  to  are  much  less  in  using  absorb- 


Fig.  491- 

taining    sutures 
anastomosis. 


:g0^ 

-Showing  size  of  incision  and  re- 
fer   Muiphy    button    in    lateral 


Fig.  492. — Suturing  intestines  in  apposi- 
tion before  incision  (Abbe). 


Fig.  493. — Showing  the  four-inch  incision 
and  sewing  of  the  edges. 


able  approximation  plates  or  the  absorbable  coupler  devised  by 
J.  Frank.  The  time  is  not  far  distant  when  the  suture  will  take  the 
place  of  all  such  mechanical  devices.  This  Avill  be  especially  true 
of  emergency  work,  which  often  limits  the  surgeon  to  needle  and 
thread  in  establishing  a  communication  between  the  intestine  above 
and  below  the  obstruction.  The  fewer  the  requirements  in  such 
cases,  the  better  will  the  operator  be  prepared  to  accomplish  what 


OPERATIVE    TREATMENT    OF    THE    OBSTRUCTION. 


791 


is  necessarx'.  The  principal  reason  that  induced  me  to  substitute 
the  perforated  decalcified  bone-plates  for  sutures  in  performing  intes- 
tinal     anastomosis 

was  to  shorten  the  ^'*'^«»fc^       a 

time  of  operation, 
and,  consequently, 
to  minimize  the 
danger  from  shock. 
A  more  extensive 
experience  with 
needle  and  thread 
has  greatly  modi- 
fied my  views  in 
this  regard.  I  now 
believe,  with  H. 
Braun,  that  the  su- 
turing can  be  com- 
pleted in  twent\- 
five  minutes,  which 
previously,  with 
less  experience,  re- 
quired twice  that 
length  of  time.  I 
have  made  many 
g  a  s  t  r  o  -enterosto- 
mies and  intestinal  anastomo.ses  by  suturing  during  the  last  five 
years,  and   the  time  occupied  by  this  part  of  the  operation   .seldom 


494. — Laplace's  anastomosis  forceps  :   A,  Closed  ; 
B,  open. 


Fig,  495. —.Application  of   I^placc'.s  anastomosis  forceps:   A,    Lateral  anastomosis;  B, 

circular  enterorrhapliy 


ccccded  more  than  from  twenty  to  thirty  minutes.      In  perlorming 


^7^2  ABDOMINAL    SECTION. 

intestinal  anastomosis  by  suturing,  the  visceral  incisions  should  be 
at  least  three  inches  in  length,  and  united  by  Lembert,  Czerny- 
Lembert,  or  Halsted's  quilt  suture.  It  is  always  necessary  to 
unite  the  intestinal  loops  between  which  an  anastomotic  opening  is 
to  be  established  by  a  row  of  seromuscular  sutures  on  the  convex 
side  before  the  visceral  incisions  are  made,  and  to  exclude  intestinal 
contents  between  two  gauze  ligatures. 

Intestinal  anastomosis  has  been  materially  simplified  and  made 
safer  by  the  use  of  the  very  ingenious  anastomosis  forceps  devised 
by  Laplace.  It  is  an  instrument  of  great  value  also  in  circular 
suturing. 

According  to  H.  Braun,  intestinal  anastomosis  is  indicated  : 

1.  After  resection,  when  the  lumina  of  the  ends  are  veiy  unequal 
in  size. 

2.  Firm  adhesions  of  intestinal  coils  with  the  adjacent  surfaces 
and  among  themselves. 

3.  Resection  of  the  lowest  portion  of  the  ileum. 

4.  Great  narrowness  of  both  intestinal  lumina. 

Allusion  has  already  been  made  to  several  other  indications  that 
should  give  preference  to  intestinal  anastomosis  over  resection  and 
circular  suturing  in  the  treatment  of  intestinal  obstruction. 

Partial  Physiologic  Exclusion  by  Anastomosis. — In  some 
cases  of  intestinal  obstruction  the  restoration  of  the  continuity  of 
the  intestinal  canal  by  resection  and  circular  enterorrhaphy  would 
necessitate  the  removal  of  several  feet  of  the  intestine  when  the 
cause  of  obstruction  in  itself  constitutes  no  intrinsic  source  of 
danger,  and  when  recovery  would  be  more  likely  to  take  place  by 
the  substitution  of  anastomosis  for  resection.  That  resection  of  a 
number  of  feet  of  the  small  intestine  is  not  always  compatible  with 
health  is  well  illustrated  by  a  case  reported  by  Baum,  in  which  he 
removed  137  cm.  from  a  woman  forty  years  of  age.  The  patient 
was  suffering  from  strangulated  femoral  hernia.  Taxis  was  only 
partially  successful.  On  opening  the  sac  an  offensive  fluid  escaped, 
and  a  portion  of  the  omentum  was  removed.  Peritonitis  followed, 
and  a  swelling  formed  in  the  abdomen  above  the  crural  ring,  which 
broke  and  a  fecal  fistula  formed  ;  rapid  emaciation  ensued,  and 
symptoms  of  strangulation  made  a  laparotomy  necessary.  A  mass 
of  intestine  was  found  twisted  into  a  bunch  that  could  not  be  un- 
raveled, and  as  it  was  surrounded  by  an  abscess,  it  was  resected 
and  the  ends  were  united  with  sutures.  Patient  recovered  from 
operation  and  improved  for  several  weeks.  Six  months  later  pro- 
gressive marasmus  resulted  in  death.  The  autopsy  revealed  no 
other  cause  of  death  except  marasmus  from  too  extensive  resection. 
In  such  a  case  I  proposed,  ten  years  ago,  that  the  twisted  adherent 
intestinal  coils,  the  cause  of  the  obstruction,  if  they  present  no  evi- 
dences of  gangrene,  should  be  left  and  permanently  excluded  from 
the  fecal  circulation  by  making  an  anastomosis  with  approximation 
plates  between  the  bowel  leading  to  and- from  the  obstructing  mass. 


PARTIAL    PHYSIOLOGIC    EXCLUSION    BY    ANASTOMOSIS.  793 

A  case  somewhat  similar  to  Baum's,  but  under  less  favorable  cir- 
cumstances, recently  came  under  my  care  where  this  plan  of  treat- 
ment was  adopted. 

Strangtilated  Hernia  :  Resection  of  Gattgrenous  Portion  ;  Additional  Obstruction 
by  a  Mass  of  Adherent  Intestinal  Loops  ;  Restoration  of  Continuity  of  Intestinal  Canal 
by  Anastomosis. — The  patient  was  a  brewer,  thirty  years  of  age,  who  had  had  an  ingui- 
nal hernia  for  several  years,  but  never  wore  a  truss.  On  lifting  a  heavy  weight  the 
swelling  became  suddenly  enlarged,  followed  by  symptoms  of  acute  strangulation.  The 
attending  physician  overlooked  the  hernia  and  treated  the  patient  for  gastritis.  Eight 
days  after  the  attack  he  was  admitted  into  the  hospital.  At  this  time  symptoms  of  acute 
diffuse  peritonitis  were  well  marked.  The  pulse  was  rapid  and  feeble,  the  extremities 
were  cold,  the  abdomen  was  tympanitic  and  excessively  tender  on  pressure,  and  there 
was  stercoraceous  vomiting.  The  hernia  was  as  large  as  a  child's  fist,  and  the  skin  cov- 
ering it  was  discolored  and  edematous.  It  was  plain  enough  that  gangrene  had  occurred, 
and  that  in  consequence  of  this  peritonitis  had  developed.  The  patient  was  given  yjjj 
of  a  grain  of  atropin  hypodermically  before  chloroforip  was  administered.  On  opening 
the  sac  fecal  matter  escaped  and  a  large  mass  of  discolored  omentum  presented  itself. 
The  sac  was  irrigated  with  a  weak  solution  of  sublimate,  and  the  omentum  was  drawn 
forward  and  wrapped  in  a  small  compress  of  gauze.  The  entire  loop  of  intestine  was 
gangrenous  and  perforated  on  the  convex  surface  at  its  highest  point.  The  parts  were 
again  irrigated  before  the  inguinal  canal  was  laid  open  by  incision.  The  omentum  was 
now  drawn  downward  until  a  healthy  portion  was  reached,  when  it  was  ligated  in  sev- 
eral parts  and  cut  off.  The  intestine  was  separated  from  its  attachments  to  the  inguinal 
canal,  and  the  gangrenous  part,  about  eight  inches  in  length,  was  excised  after  having 
previously  guarded  against  fecal  extravasation  by  applying  a  rubber  ligature  on  each  side. 
Examination  of  the  abdominal  cavity  at  this  time  showed  recent  periti^nitis.  In  drawing 
down  the  proximal  end  of  the  bowel  it  was  found  that  it  was  but  little  distended,  hence 
search  was  made  for  an  additional  obstruction  higher  up,  which  was  found  in  the  shape 
of  a  mass  of  intestinal  coils  twisted  in  every  conceivable  shape  and  so  firmly  adherent 
that  all  attempts  at  unraveling  had  to  be  abandoned.  The  intestine  above  this  point  was 
enormously  distended,  showing  that  the  bunch  of  adherent  intestines  had  caused  a  second 
obstruction.  Excision  of  from  three  to  four  feet  of  intestine  under  these  circumstances 
was  not  to  be  thought  of,  as  the  patient  would  certainly  have  died  on  the  table.  It  was 
decided  to  leave  the  obstruction  and  establish  a  communication  between  the  intestine  on 
the  distal  and  proximal  side  of  the  obstruction.  Both  resected  ends  were  closed  by  in- 
vagination and  a  few  stitches  of  the  continued  suture.  By  lateral  apposition  with  decal- 
cified perforated  bone-]jlates  an  anastomosis  was  established  between  the  distal  collapsed 
end  and  the  dilated  bowel  on  the  proximal  side  of  the  obstruction.  Before  the  approxi- 
mation sutures  were  tied,  the  intestinal  contents  were  evacuated  as  far  as  possible.  The 
whole  peritoneal  cavity  was  flushed  with  sterilized  water,  carefully  dried,  drained,  and 
the  wound  sutured.  The  toilet  of  the  peritoneum  was  made  with  a  sponge  wrung  out 
of  a  I  :  2000  solution  of  sublimate.  The  hernial  sac  was  excised,  and  the  slump  fas- 
tened in  the  inguinal  canal  by  the  deep  suture  used  in  closing  the  external  wound. 
Duration  of  operation,  less  than  an  hour.  The  patient  rallied  from  the  o[)eration,  but 
succumbed  to  the  peritonitis  at  the  end  of  twenty-four  hours.  Postmortem  :  On  remov- 
ing the  sutures  the  sac-walls  were  found  agglutinated  by  plastic  lymph.  Drain.ige  liil)e 
was  surrounded  by  a  thick  layer  of  plastic  lymph  and  coils  of  intestine  that  compleleiy 
shut  out  the  abdominal  cavity.  Only  alwut  half  of  the  omentum  remained.  The  i)art 
of  intestine  where  anastomosis  was  made  was  found  in  the  pelvis,  lying  against  the  con- 
cave surface  of  the  sacrum,  surrounded  by  numemus  recent  adhesions.  The  new  open- 
ing was  twelve  inches  above  the  ileocecal  valve.  Adhesion  between  the  serous  surfaces, 
held  in  approximation  by  the  plates,  was  sufficiently  firm  to  |)revent  leakage  under  strong 
hydro.static  pressure.      The  ojjening  was  patent. 

My  experiments  on  animals  have  demonstrated  that  pIiysio]()<;ic 
exclu.sion  of  a  certain  porti(jn  of  the  intestinal  tract  is  a  less  dan^a-r- 
ous  operation  than  exci.sion.  The  appearances  of  the  specimens 
also  tend  to  prove  that  sf>  lon^^  as  any  of  the  contents  of  the  intes- 
tines reach  the  excluded  portion,  the  peristaltic  or  antiperistaltic 
action  in  that  part  is  effective  in  forcing'  it  back  into  the  active  c.ir- 
rent  of  the  fecal  circulation.     If  the  excluded  portion  aj^ain  becomes 


794  ABDOMINAL    SECTION. 

permeable,  it  resumes  its  physiologic  function  and  again  takes  an 
active  part  in  the  processes  of  digestion  and  absorption  ;  if  the 
obstruction  remains  permanent,  it  undergoes  progressive  atrophic 
changes. 

These  experiments  were  made  and  the  results  reported  in  1887, 
As  extensive  resection  of  the  intestines  is  always  attended  by  great 
immediate  and  remote  risks  to  life,  I  concluded  at  that  time  to 
study  the  subject  of  sudden  deprivation  of  the  system  of  a  great 
surface  for  digestion  and  absorption  by  leaving  the  intestine,  but 
excluding  permanently  a  certain  portion  from  participating  in  the 
function  of  digestion  and  absorption — in  other  words,  by  resorting 
to  physiologic  exclusion. 

These  experiments  were  also  made  to  determine  the  tissue 
changes  that  would  take  place  in  the  bowel  thus  excluded,  and  to 
learn  if,  under  such  circumstances,  accumulation  of  intestinal  con- 
tents would  become  a  source  of  danger,  as  had  been  feared  by  the 
older  surgeons.  The  complete  interruption  of  passage  of  intestinal 
contents  either  by  section  and  closure  of  the  bowel  or  by  making 
an  intestinal  obstruction  of  some  kind,  and  the  restoration  of  the 
continuity  of  the  physiologically  active  portion  of  the  intestinal 
canal,  were  established  by  suturing  of  the  proximal  end  of  the  high 
section  with  the  distal  end  of  the  lower  section,  or  by  implanting 
the  proximal  end  into  the  bowel  lower  down,  the  intervening  por- 
tion of  the  intestinal  tract  in  either  case  thus  becoming  the  excluded 
portion. 

For  the  purpose  of  illustrating  the  therapeutic  value  of  physi- 
ologic exclusion  of  the  intestine  in  the  treatment  of  certain  forms  of 
intestinal  obstruction  in  which  it  is  impossible  or  impracticable  to 
remove  the  mechanical  cause,  reference  will  be  made  here  to  only  a 
few  of  the  experiments  and  their  results. 

Experiment  37. — Dog,  weight  thirty-five  pounds.  The  ileum  was  divided  just  above 
the  ileocecal  region,  and  both  ends  of  the  bowels  were  closed.  Ileocolostomy  was  done 
by  making  an  incision  about  an  inch  and  a  half  in  length  on  concave  side  of  ileum,  forty- 
four  inches  above  the  divi.sion,  and  a  similar  slit  on  convex  side  of  ascending  colon,  and 
uniting  these  wounds  by  Czerny- Lambert  sutures,  thus  excluding  from  the  intestinal  cir- 
culation forty-four  inches  of  the  bowel.  The  day  after  the  operation  the  feces  contained 
blood.  During  the  progress  of  the  case  it  was  frequently  noted  that  the  stools  were  thin, 
.sometimes  liquid.  Appetite  remained  good,  and  animal  was  well  nourished  at  the  time 
of  killing,  twenty-five  days  after  operation.  Abdominal  wall  was  well  united.  The 
omentum  and  a  few  intestinal  loops  were  adherent  to  inner  surface  of  wound.  The 
excluded  portion  was  contracted  to  more  than  one-half  of  its  usual  size,  was  atrophic,  and 
not  nearly  so  vascular  as  remaining  portion  of  intestinal  canal.  The  two  blind  ends  were 
adherent  to  each  other  and  to  adjacent  loops.  The  excluded  portion  contained  in  its  blind 
end  a  few  sharp  fragments  of  bone.  The  new  opening  between  the  ileum  and  colon, 
about  the  capacity  of  the  lumen  of  the  ileum,  was  surrounded  by  a  prominent  margin  of 
mucous  membrane  that  somewhat  resembled  the  ileocecal  valve,  to  which  still  remained 
attached  about  ten  of  the  deep  sutures.  The  coats  of  both  bowels  at  points  of  approxi- 
mation were  thickened  by  inflammatory  exudation. 

Experiment  38. — Young  cat.  The  ileum  was  divided  about  thirty  inches  above 
the  ileocecal  region.  The  distal  end  was  closed,  and  the  proximal  end  was  laterally  im- 
planted into  the  convex  side  of  the  transverse  colon,  where  it  was  fixed  by  a  double  row 
of  sutures.  Before  implantation  the  continuity  of  the  peritoneal  surface  was  procured  by 
drawing  the  peritoneum,  with  a  fine  catgut  suture,  over  the  denuded  space  left  after 
detachment  of  the  mesentery.      Although  the  animal  partook  freely  of  food,  progressive 


PARTIAL    PHYSIOLOGIC    EXCLUSION    BV    ANASTOMOSIS.  795 

marasmus  set  in,  to  which  the  cat  succumbed  eleven  days  after  the  operation.  Abdom- 
inal wound  was  completely  healed.  Union  of  implanted  ileum  with  colon  was  perfect 
and  there  was  no  peritonitis.  Excluded  portion  was  empty.  Bowel  above  implantation 
was  somewhat  dilated. 

ExPERlMF.NT  40. —  The  entire  ileum  was  excluded  in  a  cat  by  dividing  the  intestine 
at  its  junction  with  the  jejunum,  closure  of  distal  end,  and  making  a  jejunocolostomy  by 
implantation  of  the  proximal  end  into  a  slit  of  the  transverse  colon  at  a  point  opposite 
the  mesocolon.  The  cat  remained  in  good  condition  until  killed,  fifteen  days  after  oper- 
ation. No  vomiting  occurred,  and  movements  from  bowels  were  normal.  Abdominal 
wound  was  completely  closed.  There  was  no  peritonitis,  and  jejunum  at  point  of  im- 
plantation was  firmly  united.  New  opening  in  colon  was  the  size  of  the  lumen  of  the 
ileum.      E.xcluded  portion  was  empty,  contracted,  and  anemic. 

Experiment  41. — Large  mastiff.  The  small  intestine  was  divided  six  and  a  half 
feet  above  the  ileocecal  region,  the  distal  end  closed,  and  the  proximal  end  implanted 
into  an  incision  of  the  transverse  colon  large  enough  to  receive  it  at  a  point  opposite  the 
mesocolon.  Suturing  was  done  exclusively  with  fine  silk.  For  three  weeks  the  dog 
appeared  quite  well,  ate  well,  and  the  discharges  from  the  bowels  were  normal.  From 
this  time  the  emaciation,  which  commenced  soon  after  the  operation  was  done,  began  to 
increase  rapidly,  the  animal  began  to  refuse  food,  and  died  of  marasmus  thirty-two  days 
after  operation.  There  was  no  peritonitis.  Excluded  portion  was  empty  and  reduced 
one-half  in  size.  The  coats  of  the  bowels  were  very  much  attenuated,  and  the  vessels 
hardlv  half  the  normal  size.  Only  three  feet  and  five  inches  of  the  small  intestine 
remained  for  physiologic  action.  New  opening  in  colon  was  sufficiently  large  to  permit 
the  introduction  of  the  index-finger  as  far  us  the  first  joint.  On  slitting  open  the  colon 
the  point  of  juncture  with  the  jejunum  upon  the  inner  surface  was  marked  by  a  slight 
ridge  of  mucous  membrane  that  bore  a  faint  resemblance  to  the  ileocecal  valve. 

For  .some  rea.son  that  it  is  difficult  to  explain  .satisfactoril)',  in 
animals  where  the  same  length  of  intestine  was  physiologically 
excluded,  as  in  the  rejection  experiments,  the  appetite  never  be- 
came so  voracious  and  the  remaining  portion  of  intestine  did  not 
undergo  the  same  degree  of  compensatory  hypertrophy  as  in  the 
excision  experiments.  Theoretically,  two  explanations  might  be 
advanced  :  first,  in  shortening  the  intestinal  canal  by  resection  an 
extensive  vascular  district  is  cut  off  by  ligation  of  the  mesentery, 
and  it  is  but  reasonable  to  assume  that  the  circulation  in  the 
remaining  branches  of  the  mesenteric  artery  would  be  increased, 
and  consequently  the  functional  activity  of  the  organs  supplied  by 
them  augmented;  secondly,  in  cases  of  physiologic  exclusion  by 
lateral  apposition  it  is  po.s.sible  that  at  least  some  of  the  fluid  con- 
tents reached  the  excluded  portion,  from  which  a  certain  amount 
might  still  have  become  absorbed.  The  exclusion  was  c()mi:)lete, 
or  nearly  so  ;  hence  we  must  conclude,  from  the  postmortem  appear- 
ances, that  in  nearly  every  instance  the  excluded  iK)rtion  presented  an 
atrophic,  contracted  condition  and  was  only  sparingly  supplied  with 
blood-vessels.  From  a  practical  standpoint  these  experiments  teach 
us  that  a  limited  portion  of  the  intestinal  canal  can  be  permanently  ex- 
cluded from  the  proce.s.ses  of  digestion  and  absorption  in  proper  ca.ses 
by  operative  measures,  without  incurring  any  risk  f)f  fecal  accumula- 
tion in  the  excluded  part.  These  exi)erinK-nts  demonstrate  also  that 
phy.siologic  exclusion  of  a  certain  portion  of  the  inte.stinal  tract  is  a 
le.ss  dangerous  operation  than  excisioiL  and  that  in  certain  ca.ses  of 
intestinal  obstruction,  where  excision  has  been  heretofore  i)ractised, 
it  can  be  resorted  to  as  a  substitute  ff)r  this  operation  in  cases 
where  excision   is  impracticable  or  when   the  |)athologi<-  cntiitions 


^^6  ABDOMINAL    SECTION. 

that  have  caused  the  obstruction  do  not  in  themselves  constitute  an 
intrinsic  source  of  immediate  or  remote  danger  to  life.  The  post- 
mortem appearances  of  the  specimens  of  these  experiments  tend  to 
prove  that  as  long  as  any  of  the  contents  of  the  intestines  reach  the 
excluded  portion,  the  peristaltic  or  antiperistaltic  action  in  that  part 
is  effective  in  forcing  it  back  into  the  active  current  of  the  intestinal 
circulation. 

Complete  Physiologic  Exclusion. — At  the  time  the  experiments 
on  partial  physiologic  exclusion  were  made,  a  few  attempts  to  ren- 
der the  exclusion  complete  were  instituted,  but  it  soon  became 
apparent  that  this  was  incompatible  with  the  life  of  the  animal 
without  establishing  a  fistulous  opening  communicating  with  the 
excluded  segment  of  the  intestine.  In  the  few  experiments  made, 
both  ends  of  the  excluded  portion  were  closed  by  suturing  and  the 
continuity  of  the  remaining  portion  of  the  intestinal  canal  was 
restored  by  circular  enterorrhaphy.  The  results  were  in  every 
instance  very  similar  to  an  experiment  of  the  same  kind  reported  by 
F.  Mall. 

Halsted  and  Mall's  experiment : 

"  A  large  dog  was  operated  upon  by  Dr.  Halsted  to  isolate  a  loop  of  intestine.  The 
ends  of  the  separated  loop  were  sutured  together  by  Lembert's  method,  and  the  two 
remaining  cut  ends  of  the  intestine  were  likewise  stitched  together  so  as  to  reestablish 
the  continuity  of  the  alimentary  canal  (Halsted,  loc.  cit.,  p.  7).  The  dog  made  an  easy 
recovery  after  the  operation,  and  appeared  perfectly  well  until  February  1st,  when  he 
gradually  began  to  sink.  On  February  9th  the  dog  was  very  weak  and  apparently 
dying.  It  was  therefore  decided  to  make  an  exploratory  operation.  Upon  opening 
the  animal  it  was  found  that  the  loop  was  enormously  distended  with  fluid.  The  loop 
was  removed,  and  now  could  be  more  carefully  examined.  The  suture  had_  healed  very 
nicely,  so  that  the  isolated  loop  formed  an  oval  with  a  continuous  lumen.  Peculiar  ver- 
micular waves  were  now  seen  to  pass  around  the  loop.  A  pipet  manometer  was  intro- 
duced, and  although  the  waves  still  continued,  there  was  no  variation  in  the  fluid  in 
the  tube,  although  the  least  pressure  on  the  intestine  showed  that  the  manometer  was  not 
plugged.  The  oval  formed  by  the  loop  measured  in  the  long  diameter  15  cm.,  and  in 
the  short  diameter  11^  cm.,  while  the  diameter  of  the  intestine  was  from  4j^  to  5  cm. 
There  were  375  c.c.  of  dirty,  black-colored  fluid  within  the  loop,  which  was  full  of  bac- 
teria and  epithelial  cells  and  did  not  convert  starch  into  sugar. 

"  Microscopic  Examination  of  the  Walls. — The  muscle  layers  are  hypertrophied, 
the  longitudinal  muscle  being  thicker  than  the  circular,  and  the  muscularis  mucosae  is 
also  enormously  thickened,  showing  that  the  longitudinal  layers  have  thickened  more 
than  the  circular.  The  muscle-fibers  are  greatly  thickened  and  contain  many  vacuoles, 
especially  about  the  nuclei.  There  is  a  great  scarcity  of  nuclei  in  the  fibers,  which  is  in 
inverse  proportion  to  the  hypertrophy  of  the  layers,  more  frequent  in  the  muscularis 
mucosae  than  in  the  longitudinal  coat,  and  more  frequent  in  the  longitudinal  than  in  the 
circular.  It  is  very  natural  that  the  coat  which  is  most  thickened  should  contain  most 
nuclei,  but  even  in  the  most  thickened  coat,  the  muscularis  mucosae,  the  nuclei  are  less 
frequent  than  normal.  The  villi  are  very  rich  in  leukocytes,  and  the  capillaries  are  well 
filled  with  the  same — suggesting  inflammation.  The  lower  ends  of  the  crypts  are  dilated 
and  irregular,  but  at  no  point  are  they  found  breaking  through  the  muscularis  mucosae. 
The  stratum  granulosum  does  not  show  a  smooth  outline,  and  is  filled  with  many  fine 
granules  which  often  appear  to  be  micrococci." 

Later  complete  physiologic  exclusion  with  the  formation  of  a 
fistulous  opening  communicating  with  one  or  both  ends  of  the  ex- 
cluded portion  came  to  the  notice  of  the  profession  through  the 
writings  of  European  experimenters.  Modified  in  this  way,  the 
operation  is  occasionally  indicated  when  the  obstructing  portion  of 


ENTERECTOMY.  707 

the  intestinal  canal  thus  excluded  is  amenable  to  successful  topical 
treatment,  as  may  be  the  case  in  more  or  less  diffuse  intestinal 
tuberculosis  with  or  without  stenosis.  Practically,  however,  the 
same  therapeutic  benefits  are  derived  from  partial  physiologic  exclu- 
sion, which  does  not  impl)-  the  necessity  for  the  establishment  of 
one  or  two  intestinal  fistula,  always  a  source  of  disappointment  and 
discomfort  to  the  patient. 

Laparo-enterotomy.— Enterotomy  has  already  been  referred  to 
as  a  surgical  theiapeutic  resource  in  the  treatment  of  intestinal 
obstruction  from  impaction  by  abdominal  section. 

Incision  of  the  bowel  for  the  removal  of  obstruction  during 
laparotomy  is  indicated  when  the  obstruction  is  due  to  the  presence 
of  a  foreign  body,  a  concretion,  an  enterolith,  or  a  pedunculated 
benign  polypoid  tumor.  In  the  removal  of  a  foreign  body,  a  con- 
cretion, or  an  enterolith  not  amenable  to  removal  by  siibmural 
crushing  or  fragmentation  with  a  needle,  the  incision  for  extraction 
should  not  be  made  over  the  seat  of  impaction,  as  this  part  of  the 
intestine  has  undergone  changes  unfavorable  to  the  satisfactory 
healing  of  the  visceral  wound.  It  is  much  better  in  such  ca.ses  to 
make  the  incision  in  a  healthy  part  of  the  intestine,  an  inch  or  two 
below  the  impaction,  and  then  crush  the  foreign  body  by  instru- 
ments introduced  through  the  incision,  if  it  can  not  be  extracted 
safely  without  fragmentation.  The  removal  of  a  nonmalignant 
pedunculated  polypoid  tumor  is  to  be  accomplished  by  making  an 
incision  on  the  convex  surface  of  the  bowel  large  enough  to  admit 
of  dragging  the  tumor  through  it.  after  which  the  ba.se  of  the  pedicle 
is  transfixed  by  a  double  ligature  and  tied,  the  tumor  cut  off,  and 
the  wound  closed  in  the  usual  manner. 

Enterectomy. — Enterectomy  is  indicated  when  tlie  obstruction 
is  due  to  a  malignant  tumor,  if  it  is  possible  to  remove  the  disease 
completely  ;  also  for  the  removal  of  benign  tumors  that  can  not  be 
exci.sed  by  enterotomy,  and  in  all  cases  where  gangrene  has  been 
cau.sed  by  constriction,  compression,  or  overdistention.  Carcino- 
matous stcno.sis  is  met  with  most  frequently  in  the  large  intestine, 
while  the  causes  that  result  in  gangrene  are  most  common  above  the 
ileocecal  valve.  For  malignant  di.sease  resection  should  be  done  if 
the  entire  tumor  and  all  infected  glands  can  be  removed  completely 
and  with  .safety.  I^ven  if,  on  account  of  loss  of  substance,  circular 
enterorrhaphy  can  not  be  made  in  such  ca.ses,  the  continuity  of  the 
inte.stinal  canal  can  be  restored  by  lateral  implantation  or  by  lateral 
appo.sition  with  decalcified  bone  discs.  Immediate  circular  enteror- 
rhaphy after  re.section  for  intestinal  ob.stniction  has  always  been 
attended  by  a  great  mortality,  for  reasons  mentioned  elsewhere.  In 
a  .series  of  thirty-five  reset  tions  of  the  large  intestine  that  Weir 
collected  when  .symptoms  of  obstruction  indicated  the  operation,  the 
mortality  amounted  to  100  per  cent.  Reichel  has  al.so  shown  that 
re.section  of  the  small  intestine  for  conditions  giving  ri.se  toob.struc- 
tion   gave  a  mortality  of  75   per  cent,,  whereas  in  secondary  resec- 


798 


ABDOMINAL    SECTION. 


tion  for  an  artificial  anus  the  mortality  is  reduced  to  37  per  cent.,  a 
statement  that  is  supported  by  Makins  in  his  report  of  I  5  deaths  in 
39  resections  for  artificial  anus.  If,  after  the  resection  is  made,  a 
primary  circular  enterorrhaphy  is  not  made,  Hahn  recommends,  so 
as  to  preserve  the  advantages  of  a  clean  wound  and  yet  to  allow  the 
escape  of  feces,  that  the  intestine  should  be  closed  tightly  around  a 
rubber  tube,  which  is  left  projecting  some  distance  for  this  purpose. 


Fig.  496.  —  Enterectomy  :  <?,  Coiistiictioii  of  bowel  on  both  sides  beyond  the  limits 
of  resection  ;  manner  of  ligating  mesentery  ;  line  of  incision  ;  b,  suturing  of  intestine 
and  mesentery  (after  Kocher). 

In  the  removal  of  a  tumor  of  the  cecum  with  partial  resection 
of  the  intestinal  wall  it  ma)-  be  advisable  to  follow  the  example  of 
Porter  in  restoring  the  continuity  of  the  intestinal  canal  by  suturing. 
In  his  case  a  part  of  the  circumference  of  the  cecum,  including  a 
portion  of  the  ileocecal  valve,  was  resected  for  the  cure  of  a  fecal 
fistula.  The  wound  was  closed  by  slitting  up  a  portion  of  the 
ileum  from  the  seat  of  resection  and  uniting  the  margins  of  this 


F'g-  497-— Intestinal  needles  :   a,  Kelly's;   b,  Frank's;   r,  Mayo's. 

wound  with  the  resected  surface   of  the  cecum.      The   patient  re- 
covered. 

In  cases  where  the  lumina  do  not  correspond,  it  is  advisable  to  fol- 
low the  suggestion  first  made  by  Wehr  in  performing  pylorectomy — 
viz.,  to  cut  the  end  of  the  narrower  part  of  the  bowel  not  trans- 
versely, but  sufficiently  obliquely  so  that  the  circumference  of  the 
oblong  opening  will  correspond  to  the  lumen  of  the  larger  end  of 
the  bowel.  The  obliquity  should  always  be  made  at  the  expense 
of  the  convex  portion  of  the  bowel,  so  as  to  interfere  as  little  as 
possible  with  the  vascular  supply  from  the  mesenteric  side.      If  the 


ENTEKECTO.MV. 


799 


Fig.    498. — Omental    graft    over    line    of 
suturing  after  circular  enterorrhaph)-. 


obliquity  of  the  incision  should  not  equalize  sufficiently  in  size  the 
two  lumina  for  suturing,  the  difference  can  be  corrected  by  incisin<T 
longitudinall\-  the  convex  side  of  the  small  end.  ^ 

Madeluni,r,  in  resecting  the  bowel,  makes  his  incisions  somewhat 
obhquelx-  in  the  same  direction,  for  the  purpose  of  guarding   more 
effecti\ely  against   gangrene   on 
the    convex   side   of  the    bowel 
after  circular  enterorrhaphy.     In 
very  extensi\e   resection   of  the 
colon,   where   the   possibility   of 
circular  suturing  is  precluded  on 
account  of  the   impossibility  of 
approximating  the  cut  ends,  an 
artificial   anus   should    never  be 
established,    as    no     subsequent 
treatment  could  restore  the  con- 
tinuity  of   the    intestinal    canal. 
Two  such   cases   were    reported 
by  Hahn.      It  is  pos.sible  that,  in  the  future,  experimental   research 
will  pro\e  the  practicability  of  restoring  such  defects  by  a  plastic 
operation  consisting  of  transplantation  of  a  corresponding  portion 
of  the  small  intestine  between  the  separated  ends,  a  procedure  that 
would  necessitate  circular  suturing  at  three  different  points.      Until 
it  has  been  shown  that  some  such  plan  is  feasible,  the  surgeon  must 
content  himself  with  establishing  an  anastomosis  between  the  closed 
proximal  and  distal  ends  by  lateral  anastomosis.     The  latter  proce- 
dure offers  all  the  advantages  to  be  derived  from  approximation  and 
keeping  in   uninterrupted  coaptation   a    large   serous  surface,   with 
immobilization  of  the  parts  it  is  intended  to  unite  during  the  process 

of  repair.  In  circumscribed 
gangrene  due  to  decubitus 
and  involving  not  more  than 
one-half  of  the  circiunference 
of  the  bowel,  affecting  its 
lateral  or  convex  surfaces, 
such  as  is  caused  by  con- 
striction b\-  a  narrow  banti, 
resection  is  not  necessary. 
After  the  C(Mistriction  has 
been  removed,  the  gangren- 
ous sp<jt  is  turn<:(l  inward  and 
is  covered  b\' suturing  the  ad- 
jacent healtii)'  margins  of  the 
bowel  over  it.  The  .serous  surfaces  unite  rapid  1\',  so  that  perfora- 
tion during  the  .separation  of  the  gangrenous  part  is  |)rcventcd  by 
union  of  the  .serous  surfaces  (jver  it.  When  a  whole  loop  or  a 
number  of  loops  of  the  intestine  present  evidences  of  gangrene  from 
constriction,  the  indications  for  resection  are  clear  as  affoniiu-'  the 


^'S-  499- — Oblique  section  of  smaller  end 
of  intestine  to  equalize  the  lumina  of  the  cut 
ends 


8oO  ABDOMINAL    SECTION. 

only  possible  chance  of  preventing,  death  from  sepsis  or  perforation. 
Unfortunately,  in  such  cases  septic  peritonitis  has  usually  set  in 
before  the  operation  is  performed,  and  it  becomes  necessary,  after 
the  resection  has  been  made  and  the  continuity  of  the  intestinal 
canal  restored  by  approximation  plates,  to  treat  the  peritonitis  by 
flushing  the  abdominal  cavity  with  warm  saline  solution  and  disin- 
fecting with  some  mild  antiseptic,  as  a  one -third  per  cent,  solution 
of  salicylic  acid,  as  advised  by  Mikulicz.  Drainage  in  such  cases 
becomes  a  necessity. 

The  different  kinds  of  intestinal  clamps  used  for  the  purpose  of 
preventing  fecal  extravasation  are  more  harmful  than  useful.  They 
endanger  the  vitality  of  the  intestinal  wall  from  compression,  and 
are  always  in  the  way  of  the  hands  of  the  operator.  In  safety  and 
efficiency  they  can  not  compare  with  strips  of  gauze  or  a  rubber 
band  passed  through  a  tunnel  made  in  the  mesentery  near  the  bowel 
with  a  locked  pair  of  hemostatic  forceps,  and  tied  only  with  suffi- 
cient firmness  to  guard  against  the  escape  of  fecal  contents.  The 
points  of  constriction  must  be  at  a  safe  distance  from  the  lines  of 
resection,  and  before  tying  the  constrictors  the  part  to  be  resected 
should  be  carefully  emptied.  The  mesentery  should  not  be  excised, 
as  was  formerly  done,  but  should  be  tied  with  fine  silk  in  small  sec- 
tions before  the  resection  is  made  (Fig.  496). 

It  still  remains  an  open  question  to  what  extent  resection  of  the 
small  intestine  can  be  performed  with  impunity.  It  is  true  that 
Koeberle,  Kocher,  and  Baum  have  successfully  removed  respec- 
tively 2.05  m.,  160  cm.,  and  137  cm.  of  the  small  intestine  in  the 
human  subject,  but,  while  two  of  the  patients  do  not  appear  to  have 
suffered  any  ill  effects  in  consequence  of  the  removal  of  so  large  a 
surface  for  digestion  and  absorption,  in  Baum's  case  death,  which 
supervened  six  months  after  the  operation,  was  attributable  clearly 
to  marasmus,  brought  about  by  the  extensive  intestinal  resection. 
As  in  a  number  of  pathologic  conditions  of  the  intestinal  canal,  as 
multiple  strictures,  gangrene,  and  multiple  gunshot  wounds,  where 
the  wounds  are  large  and  in  close  proximity,  it  may  become  neces- 
sary to  resort  to  extensive  resection,  it  becomes  an  important  matter 
for  the  surgeon  to  know  how  much  of  the  intestinal  tract  can  be 
removed  without  any  immediate  or  remote  ill  consequences. 

The  immediate  danger  attending  such  an  operation  is  the  trau- 
matism, which,  of  course,  will  be  proportionate  to  the  length  of  the 
piece  of  intestine  removed,  while  the  remote  consequences  are  due 
to  impairment  of  the  function  of  digestion  and  absorption  caused 
by  the  shortening  of  the  intestinal  canal.  With  a  view  to  obtaining 
additional  light  on  these  important  questions  I  made  a  number  of 
experiments  in  1887.  Only  a  few  will  be  related,  for  the  purpose 
of  presenting  points  of  great  interest. 

Experiment  28. — Dog,  weight  thirty-six  pounds.  Mesentery  was  tied  in  several 
sections  with  catgut  ligatures  ;  ileum  was  divided  just  above  the  ileocecal  valve;  six  feet  of 
the  small  intestine  were  excised,  and  the  ends  united  by  Czerny-Lembert  sutures.     On 


ENTERECTOMY.  80I 

the  third  day  the  fecal  discharges  were  bloody.  Although  the  appetite  remained  good 
and  the  dog  was  allowed  to  eat  as  much  as  he  desired,  he  lost  several  pounds  in  weight 
during  the  first  week.  On  the  third  day  the  abdominal  wound  opened,  as  the  sutures 
had  cut  through,  necessitating  resuturing.  After  this  time  the  wound  healed  kindly. 
There  were  three  or  four  fluid  fecal  discharges  during  twenty-four  hours.  The  character 
of  the  discharges  remained  the  same,  and  several  microscopic  examinations  made  at  dif- 
ferent times  revealed  the  presence  of  free  undigested  fat.  The  dog  was  kept  busy  eating 
most  of  the  time,  and  although  the  most  nourishing  food  was  furnished,  he  emaciated  to 
a  skeleton.  He  was  killed  one  hundred  and  sixty-one  days  after  the  operation.  Maras- 
mus was  extreme,  and  hardly  a  trace  of  fat  could  be  found  anywhere  in  the  tissues. 
.Stomach  was  enlarged  to  three  or  four  times  its  normal  size,  and  distended  with  food.  A 
slight  thickening  of  the  wall  of  the  gut  indicated  externally  the  site  of  suturing,  and  the 
lumen  of  the  bowel  at  this  point  was  slightly  diminished  in  size.  At  point  of  operation 
a  loop  of  intestine  was  found  adherent  and  somewhat  contracted.  The  remaining  por- 
tions of  the  small  intestine,  only  forty-five  inches  in  length,  seemed  to  have  undergone 
compensatory  hypertrophy,  as  the  coats  were  much  thickened  and  exceedingly  vascular. 
At  the  seat  of  suturing  the  mucous  membrane  presented  a  slight  circular  prominence. 
Pancreas,  liver,  and  spleen  were  normal  in  size  and  appearance. 

Experiment  29. — Medium-sized  adult  dog.  Mesentery  was  tied  in  several  sec- 
tions, and  eight  feet  and  two  inches  of  the  small  intestine,  from  ileocecal  region  upward, 
were  excised  and  the  ends  sutured  in  the  usual  manner.  On  the  following  day  the  dog 
vomited,  and  blood  was  seen  to  escape  from  the  abdominal  wound.  Death  followed 
three  days  after  operation.  The  abdominal  cavity  was  filled  with  fluid  and  coagulated 
blood,  which,  on  closer  inspection,  was  found  to  have  escaped  from  one  of  the  stumps 
of  the  mesentery  where  the  catgut  ligature  had  slipped  off. 

E.XI'ERIMENT  30. — Scotch  terrier,  weight  ten  pounds.  Mesentery  was  ligated  in 
parts  with  catgut  ligatures,  the  ileum  was  divided  four  inches  above  the  ileocecal 
region,  fifty  inches  of  the  small  intestine  were  excised,  and  the  continuity  of  the 
intestinal  canal  was  restored  by  the  usual  method  of  suturing.  Some  difficulty  was 
experienced  in  suturing,  as  the  lumen  of  the  upper  end  was  considerably  larger  than 
that  of  the  lower.  Until  four  weeks  after  the  operation  the  dog,  although  eating 
well,  seemed  to  become  more  and  more  emaciated.  After  this  time  he  gained  somewhat 
in  weight  until  killed,  forty-seven  davs  after  the  resection.  During  the  whole  time  the 
feces  were  either  fluid  or  only  semisolid,  and  at  different  times  contained  free  undigested 
fat.  Appetite  was  most  of  the  time  voracious.  There  were  no  adhesions  to  abdominal 
wound.  Omentum  was  adherent  to  visceral  wound  and  to  bowel.  The  site  of  operation 
was  indicated  by  a  slight  depression  on  the  surface  of  the  bowel.  On  palpation,  a  ring- 
like thickening  was  felt,  corresponding  to  the  united  ends  of  the  bowel.  Bowel  above 
seat  of  resection  was  somewhat  enlarged.  On  cutting  into  the  bowel  the  point  of  union 
was  indicated  by  a  circular  prominence  of  mucous  membrane.  Nine  of  the  deep  sutures 
were  found  still  attached  to  the  mucous  membrane.  The  entire  tract  of  the  small  intes- 
tine that  remained  measured  only  two  feet  and  ten  inches  in  length. 

EXPERIME.NT  31. — Adult  Maltese  cat.  The  mesentery  was  tied  in  five  sections  with 
catgut  ligatures  corresponding  to  twenty-nine  inches  of  the  ileum  which  were  excised. 
Previous  experience  in  circular  enterorrhaphy  had  proved  that  perforation  is  most  likely 
to  take  place  on  the  mesenteric  side  of  the  bowel,  where,  on  account  of  the  triangular 
place  made  by  the  reflections  of  the  peritoneum,  the  muscular  coat  is  not  covered  by 
serous  membrane.  To  obviate  this  difficulty  continuity  of  the  serous  covering  of  the  ends 
of  the  bowel  before  suturing  was  secured  by  drawing  the  peritoneum  over  this  raw  surface 
by  a  fine  catgut  suture.  The  mesentery  was  detached  only  to  a  sufficient  extent  to  apply 
the  second  row  of  sutures.  The  fine  catgut  suture,  to  ajjproximate  the  edges  of  the  peri- 
toneum, must  be  applied  near  the  margin  of  the  divided  end  of  the  bowel,  so  that  the 
knot  will  n<jt  interfere  with  the  accurate  coaptation  of  the  serous  surface  between  the  deep 
and  superficial  row  of  sutures.  This  modification  of  circular  suturing  was  adopted  for 
the  first  time  in  this  case.  Although  the  animal  manifested  no  untoward  symiitoms  and 
the  appetite  remained  good,  the  marasmus  was  ])rogressive  until  the  time  of  killing, 
twelve  days  after  the  excision.  Abdominal  wound  was  n(H  completely  united.  Intestinal 
wound,  which  was  two  inches  above  the  ileocecal  region,  was  completely  healed.  The 
sutured  surface  was  adherent  to  loop  of  bowel,  which  caused  a  sharp  flexion.  Intestine 
aljove  this  point  was  somewhat  dilaterl  and  partially  distended  with  fecal  accumulation. 
Slight  contraction  of  the  lumen  (jf  bowel  by  circular  bulging  of  mucous  membrane,  in 
which  most  of  the  deep  sutures  remainerl  fixed.  The  jjostmortem  ajipearance  j)oints  to 
partial  obstruction  at  point  of  flexi(;n  ;  remaining  portion  of  small  intestine  measures 
only  twenty-one  inches  in  length. 

Kxi'KRiMKNT  32. — Medium  sized  Maltese  cat.  Mesentery  was  tied  in  sections, 
thirty-fcjur  inches  of  the  small  intestine  were  excised,  and  the  divided  ends  were  united  in 
5> 


802  ABDOMINAL    SECTION. 

the  same  manner  as  in  the  preceding  case,  special  care  being  taken  to  secure  an  uninterrupted 
peritoneal  surface  for  divided  ends  before  suturing.  Appetite  remained  good,  but  pro- 
gressive marasmus,  which  appeared  at  once,  continued  and  proved  the  direct  cause  of 
death  twenty-one  days  after  the  excision.  Abdominal  wound  was  firmly  united.  There 
was  no  peritonitis.  Visceral  wound  was  completely  united,  and  intestine  at  site  of  oper- 
ation was  covered  with  adherent  omentum. 

Experiment  35. — Excision  of  Entire  Colon  and  Two  Inches  of  Ileum  in  a  Cat. — 
A  triangular  piece  was  excised  from  distal  end  to  narrow  the  bowel  sufficiently  so  that  its 
lumen  should  correspond  to  that  of  the  ileum.  The  ileum  and  rectum  were  then  united 
by  Czerny-Lembert  sutures.  The  animal  never  rallied  from  the  prolonged  operation,  and 
died  of  shock  two  hours  later. 

The  results  of  these  experiments  speak  for  themselves.  In  all 
cases  of  extensive  resection  of  the  small  intestine  where  the  resected 
portion  exceeded  one-half  of  the  length  of  this  portion  of  the  intes- 
tinal tract  where  the  animals  survived  the  operation,  marasmus 
followed  as  a  constant  result,  although  the  animals  consumed 
large  quantities  of  food.  The  experiments  on  partial  enterec- 
tomy  illustrate  conclusively  that  for  wounds  of  the  convex  side 
of  the  intestine,  where,  from  the  nature  of  the  injury,  transverse 
suturing  is  impossible,  longitudinal  approximation  and  suturing  can 
be  safely  done,  provided  at  least  one-half  of  the  lumen  of  the  bowel 
can  be  preserved.  If  the  stenosis  is  carried  beyond  this  point,  there 
is  great  danger  that  the  inflammatory  swelling  following  the  opera- 
tion will  still  further  narrow  the  tube  and  lead  to  the  most  serious 
consequences,  due  to  intestinal  obstruction,  and  place  the  visceral 
wound  in  the  most  unfavorable  condition  for  the  healing  process. 

Partial  enterectomy  on  the  concave  side  of  the  bowel  for  a 
defect  of  any  considerable  size  is  never  admissible,  as  it  is  sure  to 
be  followed  by  gangrene  or  pathologic  flexion  of  the  bowel. 

Direct  Treatment  of  Obstruction  in  Strangulation  by  a 
Band  or  Diverticulum,  Flexion,  or  Adhesion  of  the  Intestines. 
— The  most  favorable  cases  of  intestinal  obstruction  for  lapar- 
otomy are  those  where  the  obstruction  is  due  to  constriction 
from  a  narrow  Hgamentous  band.  The  history  of  such  cases 
usually  points  to  an  antecedent  attack  of  localized  peritonitis. 
One  or  more  of  the  adhesions  during  the  course  of  time  are  drawn 
out  into  a  band,  under  which  the  intestine  is  caught,  and  strangula- 
tion takes  place  in  the  same  manner  as  in  strangulated  hernia. 
These  are  the  cases  of  intestinal  obstruction  which,  if  left  alone, 
almost  without  exception  result  in  death  ;  if  submitted  to  an  early 
operation,  they  are  cured  by  one  stroke  of  the  scissors.  If  the 
strangulated  loop  presents  no  evidences  of  gangrene  and  no  signs 
of  decubitus  are  found  at  the  point  of  compression,  the  strangula- 
tion is  relieved  by  cutting  the  bands,  and,  for  the  purpose  of  pre- 
venting a  recurrence  of  the  strangulation  from  the  same  cause,  it 
is  necessary  to  trace  the  band  to  its  points  of  fixation  and  resect 
it  between  two  ligatures.  A  diverticulum  of  the  small  intestine, 
remnants  of  the  vessels  of  the  vitelline  duct,  or  the  appendix  vermi- 
formis  have  often  been  found  as  a  cause  of  constriction  when  the 
free  extremity  of  these  structures  had  become  adherent  to  some 


OBSTRUCTION    BY    BANDS. 


803 


fixed  point,  and  it  is  always  necessaiy  to  make  a  close  examination 
of  a  constricting  band  before  resorting  to  cutting  instruments,  as  a 
mistake  in  recognizing  the  true  anatomic  character  of  the  obstruct- 
ing cause  might  lead  to  serious  results.  A  narrow  appendix  may 
be  tied  and  resected  the  same  as  a  ligamentous  band  when  the 
stump  is  properly  cared  for,  but  when  the  obstruction  is  caused  by 
a  diverticulum,  greater  care  must  be  exercised  in  removing  the  cause 
of  obstruction.  Many  of  the  diverticula  which  have  been  met 
with  as  a  cause  of  obstruction  were  nearly  as  large  at  their  base  as 
the  intestine  with  which  they  were  connected,  and  in  such  instances 
it  would  be  unsafe  to  rely  upon  a  ligature  at  the  resected  end  in 
effecting  permanent  ob- 
literation, as  cutting 
through  the  ligature 
might  be  followed  by 
perforation  and  death 
from  septic  peritonitis  a 
few  days  after  the  ap- 
parent recovery  of  the 
patient.  The  proximal 
end  of  such  a  resected 
diverticulum  must  be 
closed  with  the  same 
care  and  in  the  same 
manner  as  an  intestinal 
wound  of  the  same  size 
from  other  causes.  If 
the  obstruction  is  found 
to  be  due  to  flexion, 
the  mechanical  diffi- 
culty must  be  corrected 
by  separating  the  adhe- 
sions, as  the  apex  of  the 
flexion  is  generally,  if 
not  always,  adherent  to 
some  fixed  j)oint.  After 
this  has  been  done,  the  proper  .shajje  and  contour  of  the  bowel 
should  be  restored  and  its  permeability  tested  by  pushing  the 
contents  beyond  the  flexed  part,  if  this  can  be  done  without  meet- 
ing with  resistance,  and  if  the  condition  of  the  intestinal  wall  at  the 
.site  of  flexion  i)rescnts  no  .serious  tcxtural  changes,  the  intestine  is 
returned  and  the  abdominal  incision  clo.sed.  As  the  concavity  of 
the  flexion  is  usually  directed  toward  the  mesenteric  attachment, 
the  vascular  disturbances  are  most  marked  on  the  convex  surface 
of  the  bowel,  and  if  gangrene  or  [)erforation  has  taken  place,  it  is 
found  at  this  point.  In  cither  of  these  events  it  would  become 
neces.sary  to  liberate  the  intestine  by  separating  the  adhesions,  and 
then  resort  t'^  a  V-shaped  exci.sion  on  the  convex  side  of  tlic  intes- 


Fig.    500. — Strangulation   by  Meckel's  diverticulum 

(Warren  Museum). 


8o4 


ABDOMINAL    SECTION. 


tine.  The  portion  to  be  excised  must  be  of  sufficient  size  to  include 
the  diseased  tissue  and  to  enable  the  surgeon  to  rectify  the  mal- 
position by  suturing. 

Immobilization  of  a  considerable  portion  of  the  intestinal  canal 
by  a  large  blood-clot  and  extensive  parietal  and  visceral  adhesions 
may  give  rise  to  symptoms  of  intestinal  obstruction.  When  intra- 
abdominal hemorrhage  is  followed  by  a  complexus  of  symptoms 
indicative  of  the  presence  of  intestinal  obstruction,  the  abdomen 
should  be  opened  and  the  coagulated  blood  removed  by  sponging 
and  flushing  of  the  peritoneal  cavity  with  hot  saline  solutions,  and 

the  recurrence  of  the  same 
condition  prevented  by  arrest- 
ing further  hemorrhage.  A 
form  of  visceral  adhesion  be- 
tween coils  of  intestines  massed 
into  a  bunch  has  already  been 
described  as  a  cause  of  intes- 
tinal obstruction.  If  this  con- 
dition has  lasted  for  several 
days  and  the  adhesions  have 
become  firm,  it  is  absolutely 
impossible  to  unravel  the  bowel 
without  running  the  risk  of  in- 
flicting numberless  and  perhaps 
irreparable  injuries.  In  such 
instances  excision  of  the  mass, 
followed  by  circular  enteror- 
rhaphy  or  anastomosis  between 
the  intestine  above  and  below 
the  obstruction,  as  previously 
described,  present  themselves 
as  the  most  appropriate  meth- 
ods of  treatment.  Each  of 
these  operations  is  applicable 
to  special  cases  and  adapted 
to  meet  particular  indications. 
Thus,  if  any  of  the  embedded 
coils  should  present  indications  of  incipient  gangrene,  resection 
must  be  done.  If  no  such  textural  changes  are  present,  intestinal 
anastomosis  should  be  preferred,  as  by  it  the  obstruction  is  removed 
indirectly,  and  the  portion  temporarily  excluded,  after  subsidence 
of  the  inflammation  and  absorption  of  the  adhesions,  may  again 
become  permeable  and  resume  its  physiologic  functions. 

Circumscribed  parietal  adhesions  as  a  cause  of  intestinal  obstruc- 
tion are  most  commonly  met  with  in  the  pelvis,  and  on  account  of 
the  greater  frequency  of  pelvic  inflammation  in  the  female,  occur 
more  frequently  in  women  than  in  men.  Pelvic  intestinal  adhesions 
produce  obstructions  in  two  distinctly  different  ways  :  (i)  An  adhe- 


Fig.  501. — Strangulation  by  appendix  vermi- 
formis  (Warren  Museum). 


ADHESIONS. 


805 


rent  intestine  becomes  flexed  or  twisted  by  the  peristaltic  action  of 
the  free  portion,  and  obstruction  results  from  sudden  or  gradual 
stenosis  of  the  lumen  of  the  bowel.  (2)  A  portion  of  intestine 
becomes  fixed  at  each  end  by  adhesions,  and  a  loop  is  caught 
under  it,  when  obstruction  is  caused  in  the  same  manner  as  by 
ligamentous  bands. 

The  only  case  of  intestinal  obstruction  after  ovariotomy  that 
occurred  in  my  experience  was  produced  in  this  manner.  The  pedi- 
cle was  tied  and  its  surface  cauterized.  No  untoward  symptoms  until 
the  end  of  the  third  week,  when  symptoms  of  intestinal  obstruction 
appeared  suddenly  and  increased  in  intensity  in  spite  of  irrigation  of 
the  stomach  and  high  rectal  injections.  Patient  died  two  weeks 
later.  The  postmortem  showed  that  a  loop  of  the  lower  portion  of 
the  ileum  had  become  adherent  to  the  surface  of  the  pedicle,  and 
that  the  mesentery  constituted  the  second  fixed  point ;  under  this 
loop  another  loop  four  inches  in  length  had  slipped  from  above  down- 
ward, and  had  become  incarcerated  in  tiiis  position.  The  intestine 
below  the  obstruction  was  perfectly  empty,  while  above  it  it  w^is  enor- 
mously dilated  and  exceedingly  vascular  as  far  as  the  duodenum. 

Quite  a  number  of  similar  cases  have  been  reported  by  different 
operators.  In  old  cases  of  pelvioperitonitis  and  .salpingitis,  the  cause 
of  a  subsequent  attack  of  intestinal  obstruction  is  frequently  trace- 
able to  intestinal  adhesions  and  the  formation  of  ligamentous  bands. 
In  the  separation  of  such  old  adhesions  the  greatest  care  must  be 
exercised  not  to  tear  the  bowel,  as  both  the  parietal  and  visceral 
peritoneum  may  have  been  transformed  into  a  cicatricial  mass  which 
it  is  not  safe  to  separate  by  tearing.  The  separation  must  be  done 
by  careful  dissection,  which,  for  the  sake  of  safety,  is  done  rather  at 
the  expense  of  the  parietal  than  the  visceral  tissues.  Defects  of  the 
peritoneum  thus  caused  or  made  during  other  abdominal  operations 
should  be  covered  by  suturing,  by  laying  the  omentum  over  it,  or, 
if  need  be,  by  omental  grafts,  to  prevent  a  recurrence  of  such  com- 
plication. The  parietal  peritoneum  is  so  loosely  attached  almost 
everywhere  that  it  yields  sufficiently  to  cover  a  defect  at  least  two 
inches  in  width  by  suturing,  and  whenever  this  can  be  done,  it  should 
not  be  neglected,  as  surfaces  denuded  of  peritoneum  are  liable  to 
become  permanently  adherent  to  adjacent  abdominal  viscera.  If 
larger  defects  arc  to  be  covered,  the  peritoneum  can  be  cut  in  the 
shape  of  flaps,  which  can  be  rcadil}'  mobilized  and  sutured.  When 
the  omentum  is  within  reach,  this  should  be  utilized  in  covering  the 
defect. 

A  number  of  years  ago  I  made  a  series  of  experiments  on  animals 
that  demonstrated  that  when  a  piece  of  [)arietal  peritoneum  three  to 
four  inches  square  is  removed  and  not  restored  in  some  of  the  above- 
mentioned  ways,  permanent  adhesions  form  between  the  denuded 
place  and  the  organ  that  comes  in  contact  with  it.  Another  series 
of  experiments  that  it  wmild  be  too  tedious  to  describe  in  fiill  were 
made  to  show  that  peritoneal  defects  that  can  not  be  restored  by 


8o6  ABDOMINAL    SECTION. 

suturing  or  covering  with  omentum  can  be  treated  successfully  by- 
transplantation  of  an  omental  or  peritoneal  graft.  In  some  of  the 
experiments  a  piece  of  peritoneum  four  inches  square  was  removed 
from  each  side  of  the  abdominal  wall  at  corresponding  points,  and 
was  transplanted  to  opposite  sides  and  sutured  to  the  margins 
of  the  wound  with  catgut.  All  these  experiments  proved  suc- 
cessful. Omental  grafts  answered  the  same  purpose,  and  in  only 
one  instance  did  the  graft  fail  to  unite  throughout,  and  here  one  of 
its  margins  projected  into  the  median  abdominal  incision,  which  did 
not  unite  by  primary  union.  Infection  of  this  margin  led  to  gan- 
grene of  the  graft  and  septic  peritonitis. 

Toilet  of  Peritoneal  Cavity. — If  everything  that  has  come  into 
contact  with  the  abdominal  cavity  during  a  laparotomy  for  intestinal 
obstruction  has  been  rendered  aseptic  by  the  most  scrupulous  anti- 
septic precautions,  and  the  local  conditions  found  have  caused  no 
infection  and  no  soiling  of  the  peritoneal  cavity  with  intestinal  con- 
tents during  the  operation,  the  abdominal  cavity  is  aseptic  after  the 
operation  and  can  be  closed  after  the  removal  bj^  gentle  sponging 
of  any  blood  that  may  have  collected.  Unnecessary  exposure  of 
the  intestines  should  always  be  most  carefully  guarded  against  by 
hot  compresses  around  the  incision  during  intra-abdominal  explo- 
ration, and  by  keeping  the  intestines  constantly  covered  by  warm 
compresses  as  long  as  they  are  outside  the  peritoneal  cavity,  for  the 
purpose  of  preventing  infection  by  floating  microbes  and  to  guard 
against  loss  of  heat  during  the  operation.  The  case  is,  however, 
entirely  different  when  the  parts  concerned  in  the  obstruction  have 
caused  intraperitoneal  sepsis  at  the  time  the  operation  is  undertaken, 
or  when,  during  its  performance,  in  spite  of  all  care  to  prevent  it, 
the  peritoneal  cavity  has  become  contaminated  by  fecal  extravasa- 
tion. Under  these  circumstances  the  peritoneal  cavity  should  be 
flushed  with  gallons  of  hot  saline  solution  or  a  saturated  solution 
of  salicylic  acid.  The  end  of  the  glass  tube  or  rubber  tubing  of  the 
fountain  syringe  should  be  held  in  different  parts  of  the  abdominal 
cavity,  especially  in  the  deepest  portion  of  the  pelvis  and  the  lumbar 
regions,  so  as  to  direct  the  current  of  the  antiseptic  solution  out  of 
and  not  into  the  peritoneal  cavity.  After  the  abdominal  cavity  has 
been  cleansed  by  flushing,  it  is  dried  by  sponging.  In  such  cases 
drainage  should  never  be  omitted.  The  closure  of  the  external 
incision  when  intra-abdominal  pressure  is  excessive  is  greatly  facili- 
tated by  covering  the  intestines  with  a  napkin  or  thin  compress  of 
gauze,  which  is  tucked  underneath  the  margins  of  the  wound  all 
around.  All  the  sutures  should  be  introduced  before  any  of  them 
is  tied.  When  all  the  sutures  are  in  place,  they  are  tied  from  above 
downward.  If  tension  is  considerable,  it  is  necessary  to  add  two  or 
more  button  sutures,  which  are  passed  only  down  to,  but  not 
through,  the  peritoneum,  and  are  removed  as  soon  as  the  tympanites 
disappears.  A  copious  aseptic  dressing,  held  in  place  by  a  firm 
abdominal  bandage,  completes  the  operation. 


AFTER-TREATMENT. 


807 


After-treatment. — Uniform  equable  support  of  the  abdomen, 
by  strapping  and  bandages  over  the  antiseptic  absorbent  dressing, 
furnishes  efficient  support  to  the  distended  abdominal  \valls  and  the 
paretic  intestines,  and  is  not  only  grateful  to  the  patient,  but  is  an 
important  aid  in  relieving  the  distress  due  to  distention  and  peristal- 
sis. In  all  operations  for  intestinal  obstruction  efforts  should  be 
made  to  empty  the  bowel,  not  only  at  tiie  seat  of  obstruction,  but 
as  far  as  it  can  be  done,  as  such  immediate  evacuation  constitutes 
one  of  the  elements  of  success. 

J.  Greig  Smith  states  distinctly  that  "  No  case  of  operation  for 
intestinal  obstruction  is  properly  concluded  until  the  distended  bowels 
are  relieved  of  their  contents."  One  of  the  most  favorable  symp- 
toms after  a  successful  operation  for  intestinal  obstruction  is  a  spon- 
taneous action  of  the  bowels,  as  it  not  only  proxes  the  permeability 
of  the  intestinal  canal,  but  is  also  an  evidence  that  peristaltic  action 
has  been  restored.  The  retention  of  fecal  material  in  the  distended 
paretic  intestines  after  operation  for  intestinal  obstruction  is  a  condi- 
tion that  not  only  retards  recovery,  but  is  in  itself  a  grave  source  of 
danger.  Through  the  sympathetic  nerves  the  distended  intestine 
exerts  a  most  depressing  effect  on  the  cerebrospinal  centers,  while 
the  putrefactive  changes  that  are  constantly  going  on  in  the  stag- 
nant intestinal  contents  must  be  a  constant  source  of  intoxication,  and. 
at  the  same  time,  the  migration  of  septic  micro-organisms  through 
the  paretic  walls  threatens  life  from  septic  peritonitis. 

Symptoms  of  shock  are  met  by  the  administration  of  strychnin 
subcutaneously,  stimulants  by  the  rectum,  intravenous  or  subcutan- 
eous saline  infusions,  and  stimulation  of  the  peripheral  circulation 
by  dry  heat  applied  to  the  surface  of  the  trunk  and  extremities. 

Mr.  Tait  has  taught  us  the  value  of  cathartics  in  the  prevention 
of  peritonitis  after  abdominal  operations.  Would  it  not  be  rational 
to  follow  his  example  in  the  after-treatment  of  operations  for  intes- 
tinal obstruction  ?  Surgeons  have  repeatedly  made  the  observation 
that  the  paretic  intestine  above  the  .seat  of  obstruction  will  respond 
slowly  but  surely  to  mechanical  irritation,  and  it  is  logical  to  con- 
clude that  the  same  effect  would  be  produced  by  the  administra- 
tion of  a  brisk  saline  cathartic.  Dangerous  as  the  use  of  catliartus 
necessarily  must  be  before  the  obstruction  is  renioiied,  so  beneficial  may 
their  judicious  employment  be  after  the  cojitinuity  of  the  intestinal  canal 
has  been  restored  by  operatii'e  treatment. 

Thirst  is  quenched  by  sips  of  hot  water,  fragments  of  ice,  and 
saline  rectal  enemata.  Stomach -feeding  is  absolutely  contraindi- 
cated  for  the  first  forty-eight  or  seventy-two  hours,  during  which 
lime  rectal  alimentation  is  relied  upon  exclusively.  Absolute  rest 
in  the  recumbent  position  mu.st  be  enforced  until  the  visceral  and 
abdominal  wounds  have  healed.  The  administration  of  copious 
laxative  enemata  is  |)ermissible  f(;r  the  purpose  of  assisting  the  saline 
cathartics  to  restore  peristalsis,  provided  the  .scat  of  strangulation 
was  above  the  ileocecal  valve. 


CHAPTER  XXIII. 

ENTERORRHAPHY. 

Intestinal  suturing  is  technically  called  enterorrhaphy.  From 
a  practical  standpoint  intestinal  suturing  is  divided  into  (i)  lateral 
and  (2)  circular.  Lateral  enterorrhaphy  is  intended  for  the  closure 
of  gunshot,  stab,  cut,  and  punctured  wounds  of  such  size  and  so 
located  that  in  closing  them  by  sewing,  the  lumen  of  the  injured 
part  of  the  intestine  remains  sufficiently  large  for  the  free  passage 
of  intestinal  contents,  and  without  interfering  with  the  necessary 
blood  supply  to  the  injured  tissues  or  the  corresponding  segment 
of  the  bowel.  Intestinal  suturing  is  also  resorted  to  by  the  lateral 
method  in  closing  pathologic  perforations  of  limited  dimensions 
and  tears  made  during  abdominal  and  pelvic  operations,  and  after 
partial  enterectomy  for  trauma  or  the  removal  of  pathologic  pro- 
ducts or  extraction  of  foreign  impacted  bodies  from  the  lumen  of 
the  intestines  by  enterotomy.  In  selecting  the  cases  for  lateral 
suturing  the  surgeon  must  exercise  the  greatest  caution  in  deter- 
mining the  exact  location  and  extent  of  the  intestinal  defect  and  its 
influence  on  the  blood  supply  of  the  injured  or  diseased  segment 
of  the  bowel.  Oil  the  concave  side  of  the  intestine  only  incised  and 
small  punctured  wotmds  are  amenable  to  successftil  lateral  enteror- 
rhaphy,  as  wo?inds  or  perforations  involving  any  considerable  part  of  the 
mesenteric  attachment  interrupt  the  blood  supply  to  the  convex  side  of 
the  bowel  sufficiently  to  incur  danger  from  gafigrene,  and  the  suturing 
of  a  mesenteric  wound  involviiig  the  bowel-wall  to  any  considerable 
extent  is  very  liable  to  residt  in  stenosis  from  flexion  to  a  degree  which 
may  become  a  cause  of  mechanical  obstruction.  In  this  connection 
only  two  of  a  number  of  experiments  made  by  me  will  be  quoted 
to  illustrate  the  danger  incident  to  lateral  suturing  on  the  mesen- 
teric side,  and  the  treatment  of  large  defects  on  the  convex  side  by 
the  same  procedure. 

Experiment  2. — Large,  full-grown  cat.  On  the  concave  side  of  the  bowel,  about 
the  middle  of  the  ileum,  a  semilunar  piece  of  the  wall  of  the  intestine  with  the  corre- 
sponding mesentery  was  removed  and  the  wound  closed  parallel  with  the  long  axis  of 
the  bowel,  which  diminished  the  diameter  of  the  lumen  of  the  bowel  to  about  one-eighth 
of  an  inch.  It  was  noticed  during  the  operation  that  the  convex  surface  of  the  bowel 
over  an  area  corresponding  to  the  partial  excision  presented  a  cyanosed  appearance.  The 
animal  died  on  the  fourth  day  after  operation,  and  the  whole  segment  of  the  sutured  bowel 
was  found  gangrenous,  but  no  fluid  in  the  abdominal  cavity. 

Experiment  3. — Adult,  large  cat.  In  this  case  a  segment  of  the  ileum  was  emptied 
of  its  contents,  and,  before  cutting  away  a  semilunar  piece  from  the  convex  surface,  a 
back-stitch  continuous  suture  was  applied  on  the  inner  margin  of  the  proposed  line  of 
incision,  which  left  about  one-third  of  the  lumen  of  the  bowel.  After  excision  of  the 
semilunar  piece  the  margins  of  the  cut  surface  were  turned  inward  and  covered  with 
serous  surface  by  a  continuous  catgut  suture.  Several  small  passages  occurred  after  the 
operation,  but  the  animal  died  on  the  fourth  day  with  symptoms  of  intestinal  obstruction. 


ENTERORRHAPHY.  809 

The  visceral  wound  was  found  healed,  but  the  lumen  had  become  so  narrow  from  the 
inflammatory  swelling  of  the  tunics  of  the  bowel  that  it  was  entirely  inadequate  for  the 
passage  of  intestinal  contents,  and  as  a  result  of  this  operation  the  bowel  had  become 
considerably  dilated  above  the  point  of  operation. 

These  experiments  illustrate  conclusively  that  in  wounds  of  the 
convex  side  of  the  intestine,  where,  from  the  nature  of  the  injury, 
transverse  suturing  is  impossible,  longitudinal  approximation  and 
suturing  can  be  safely  done,  provided  at  least  one-half  of  the  lumen 
of  the  bowel  can  be  preserved.  If  the  stenosis  is  carried  beyond 
this  point,  there  is  great  danger  that  the  inflammatory  swelling  fol- 
lowing the  operation  will  still  further  narrow  the  tube  and  lead  to 
the  most  serious  consequences,  due  to  intestinal  obstruction,  and 
place  the  visceral  wound  in  the  most  unfavorable  condition  for  the 
healing  process. 

Experiment  2  shows  the  great  danger  of  interference  with  the 
blood  supply  from  the  mesentery  in  longitudinal  suturing  of  wounds 
on  the  concave  side  of  the  bowel,  as  such  a  procedure  is  invariably 
followed  by  gangrene  of  the  corresponding  segment  of  bowel  on 
the  convex  side. 

Circular  enterorrhaphy  is  the  procedure  by  which  the  continuity 
of  the  intestinal  canal  is  restored  after  complete  division  of  the 
bowel  or  after  excision  of  a  greater  or  less  section  for  injury  or  dis- 
ease. Circular  enterorrhaphy  is  the  ideal  method  of  accomplishing 
this  object  in  all  cases  in  which  time  and  the  general  condition  of 
the  patient  permit.  The  various  mechanical  devices  that  have  been 
brought  to  the  attention  of  the  profession  during  the  last  twelve 

A  1 

years  were  intended  mainly  as  time-saving  measures.  As  compared 
with  the  suture  and  anastomosis  and  lateral  implantation,  they  have 
come  into  wide-spread  use  as  substitutes  for  circular  suturing  in 
cases  in  which  the  cut  ends  of  the  intestine  can  not  be  united  by 
this  method,  owing  to  the  extent  of  the  defect,  fixation  of  the  parts 
to  be  approximated  by  adhesions,  or  too  great  difference  in  the  size 
of  the  lumina  to  be  united. 

A  study  of  surgical  literature  brings  the  conviction  that  the  suc- 
cessful treatment,  by  direct  operative  intervention,  of  injuries  and 
surgical  affections  of  the  intestinal  tract  is  one  of  the  mo.st  brilliant 
achievements  of  modern  surgery.  Less  than  fifty  years  ago  many 
of  the  most  famous  surgeons  regarded  the  direct  treatment  of  woinuls 
of  the  intestines  as  a  noli  me  tangerc,  under  the  belief  that  nature's 
resources  would  prove  more  successful  in  saving  the  life  of  the 
patient  than  the  surgeon's  efforts  in  closing  the  wound  by  artificial 
means.  The  intentional  infliction  of  an  intestinal  wound  by  the 
surgeon  for  the  purpose  of  correcting  mechanical  difficulties  any- 
where in  the  intestinal  canal  and  the  removal  of  life-threatening 
affections  by  operative  procedure  are  operations  that  have  been 
.seriously  discus.sed  and  exten.sively  practised  only  during  the  la.st 
twenty-five  years.  It  is  advisable  and  profitable,  during  the  present 
time,  which  has  witnes.scd  such  wonderful  advancements  in  surgery, 


8lO  ENTERORRHAPHY. 

to  make  occasionally  a  halt  in  the  restless  search  for  new  discov- 
eries and  novel  operations  to  take  a  retrospective  view  of  what  has 
been  done  in  the  past  in  certain  departments  of  surgery  that  have 
recently  been  subjected  to  such  complete  revolutionary  changes.  No 
part  of  abdominal  surgery  has  undergone  more  radical  changes 
than  the  intestinal  suture,  and  in  none  is  the  contrast  greater  between 
the  ancient  and  modern  methods. 

The  history  of  the  intestinal  suture  is  full  of  interest  to  the  stu- 
dent of  surgical  literature.  It  is  replete  with  stupendous  ignorance, 
clever  mechanical  ingenuity,  patient  experimental  research,  and  the 
careful  application  of  pathologic  knowledge  to  the  treatment  of 
injuries  and  diseases  of  the  intestinal  canal.  From  an  anatomico- 
practical  standpoint  the  history  of  the  intestinal  suture  can  be 
divided  into  three  epochs  :  (i)  ancient,  (2)  modern,  and  (3)  recent. 
The  ancient  history  extends  back  from  Lembert  (1826)  to  the  time 
of  Celsus.  The  modern  history  commenced  with  the  researches  of 
Lembert,  which  proved  that  healing  of  intestinal  wounds  takes 
place  most  constantly  and  speedily  if  the  serous  surfaces  are  brought 
and  kept  in  contact  by  the  sutures.  The  third  period  was  initiated 
by  the  introduction  of  the  aseptic  suture  by  Lister,  and  will  neces- 
sarily extend  far  into  the  future.  We  have  reason  to  believe  that 
the  technic  of  intestinal  suturing  remains  an  unfinished  chapter,  and 
that  the  ideal  method  of  uniting  intestinal  wounds  has  yet  to  be 
devised. 

In  the  presidential  address  on  *"  Enterorrhaphy  :  Its  History, 
Technic,  and  Present  Status,"  delivered  by  me  before  the  Association 
of  Military  Surgeons  of  the  United  States  in  1893,  and  published 
in  the  transactions  for  the  same  year,  I  gave  a  complete  history  of  the 
intestinal  suture  and  its  substitutes  up  to  that  time,  with  fifty-four 
figures  illustrating  the  same.  A  great  many  new  sutures  and 
mechanical  appliances  have  been  devised  and  described  since,  but 
none  of  them  marks  any  decided  improvement  in  the  technic  of 
enterorrhaphy. 

The  axiom  of  successful  intestinal  suturing,  "  peritoneum  to 
peritoneum,"  established  by  Lembert,  holds  good  to-day,  although 
several  attempts  have  been  made  to  undermine  its  force.  In  1895 
the  late  distinguished  author  and  abdominal  surgeon,  J.  Greig 
Smith,  raised  his  voice  in  opposition  to  its  universal  acceptance  and 
application  in  practice.  He  changed  his  views  in  consequence  of 
what  he  observed  in  the  healing  of  wounds  after  enterostomy  or 
colostomy.  He  found  the  adhesions  firmer  and  more  permanent 
between  a  serous  and  raw  surface  than  between  two  apposed  serous 
surfaces.  He  argued  strongly  in  favor  of  uniting  a  serous  to  a 
raw  surface  in  effecting  permanent  fixation  of  any  of  the  intra- 
abdominal organs.  The  two  closing  sentences  of  one  of  his  last 
valuable  contributions  to  abdominal  surgery  express  clearly  his 
conviction  on  this  subject : 

"Senn    went     some    way    toward    serofibrous    approximation 


METHODS.  8  I  I 

when  he  suggested  scratching  of  the  apposed  peritoneal  sur- 
faces. I  should  hke  to  see  it  carried  further,  either  into  actual 
denudation  of  one  serous  surface  or  actual  outfolding  of  both 
serous  surfaces  so  as  to  get  a  flange-stitch,  or  by  removal  of 
a  ring  of  mucous  membrane  and  env^eloping  the  intact  gut  by  the 
muscular  and  serous  coats  (Jessett- Robinson).  And  this  is  one 
purpose  of  my  writing  now,  to  suggest  further  experiments  in  in- 
testinal surgery  to  test  the  question  whether  seroserous  apposition 
with  infolding  is  really  the  best  method  of  joining  divided  bowel. 
A  cautious  application  of  accidental  results  has  convinced  me  that, 
over  the  greater  part  of  the  field  of  abdominal  surgeiy,  seroserous 
junction  is  not  the  best  ;  extended  experience  must  show  whether 
the  same  rule  holds  good  with  regard  to  intestinal  surgery.  If 
the  proof  in  this  case  goes  against  the  general  principle,  I  think 
it  is  more  likely  to  be  on  mechanical  than  on  pathological 
grounds." 

Reasoning  from  the  same  point  of  view,  Kummer  advocated  the 
removal  of  a  ring  of  mucous  membrane  by  excision  or  scraping  as 
a  preliminary  step  to  circular  suturing.  This  practice,  however,  has 
found  but  few  imitators,  and  the  law,  "  serosa  to  serosa,"  continues 
in  force  at  the  present  time  in  uniting  intestinal  wounds  by  suture 
or  any  of  its  substitutes. 

The  sutured  serous  surfaces  appear  to  become  attached  to  each 
other  before  the  completion  of  the  operation,  as  will  be  seen  from 
the  paper  of  F.  Mall  on  "  Healing  of  Intestinal  Sutures."  He 
describes  a  specimen  of  "suture  of  a  (cw  hours'  standing."  "The 
serous  coats  that  are  in  apposition  are  closely  stuck  together.  It 
has  been  noticed  frequently  by  Dr.  Halsted  and  myself  that  this 
union  takes  place  before  the  operation  is  completed.  In  a  double 
resection,  as  in  this  case,  the  suture  first  made  was  always  examined 
before  finally  closing  the  abdominal  cavity.  In  pulling  the  edges 
of  the  wound  apart,  a  fibrinous  substance  would  have  to  be  torn  in 
order  to  separate  the  edges.  There  are  in  this  substance  very  few 
leukocytes,  and  under  favorable  circumstances  primary  union  takes 
place."  What  the  author  understands  by  primary  union  is  some- 
what vague,  as  organic  union  without  granulation  and  vasculariza- 
tion is  no  longer  considered  within  the  range  of  possibilities. 

I  made  a  series  of  experiments  with  the  aim  of  studying  the 
effect  of  chemic  and  mechanical  irritation  of  the  peritoneum  in  the 
rei>arativc  process  after  intestinal  operations.  The  chenn'c  sub- 
stances used  were  the  tinctures  of  iodin  and  muriate  of  iron,  and 
mechanical  irritation  was  made  by  scarifying  the  peritoneum  with 
the  point  of  an  aseptic  needle.  The  scarification  was  made  deep 
enough  to  reach  the  sub.serous  va.scular  ti.ssucs.  It  was  expected 
that,  by  bringing  the  blood-ve.ssels  on  both  sides  in  clo.ser  contact, 
the  process  of  repair  would  be  ha.stened,  besides  securing  tissue 
stimulation  from  the  mechanical,  irritation  caused  by  the  procedure. 
Only  two  of  the  experiments  will  be  quoted  here  : 


8  I  2  ENTERORRHAPHY. 

Experiment  104. —  Triple  Ileo-ileostot?ty  by  Perforated  Decalcified  Bone-plales. — 
Three  internal  fistulte  were  made  between  the  adjacent  loops  of  the  ileum,  about  six 
inches  apart.  In  operation  No.  i  approximation  of  intact  serous  surfaces  ;  in  operation 
No.  2  the  serous  surfaces  were  painted  with  tincture  of  iron  over  an  area  corresponding 
to  the  size  of  the  plates  ;  in  operation  No.  3  the  serous  surfaces  over  the  same  extent 
were  brushed  with  pure  tincture  of  iodin.  The  animal  was  killed  forty-eight  hours  after 
operation,  and  the  following  conditions  were  noted  :  No  general  peritonitis.  All  the 
plates  firmly  in  place,  coaptating  the  serous  surfaces  accurately,  the  swelling  of  the  tunics 
of  the  bowel  serving  only  to  enhance  their  efficiency.  At  No.  i  adhesions  quite  firm, 
flexion  of  bowel,  and  marked  injection  of  serous  surfaces.  At  No.  2  no  adhesions 
between  serous  surfaces.  The  peritoneal  surfaces  to  which  the  tincture  of  iron  had  been 
applied  appeared  stained,  almost  black,  and  at  some  points  the  serous  coat  was  destroyed. 
At  No.  3  peritoneal  surfaces  stained  dark  brown,  adhesions  firm,  and  an  abundance  of 
plastic  lymph  even  beyond  the  margin  of  the  plates. 

Experiment  105. — Double  Ileo-ileosloniy  by  Approximation  Plates  and  Omental 
Grafting. — Operation  No.  i,  approximation  of  ileum  to  ileum  by  perforated  decalcified 
bone-plates;  serous  surfaces  intact.  Operation  No.  2,  similar  operation  six  inches  higher 
up,  uniting  the  same  loops,  but  painting  the  serous  surfaces  with  pure  tincture  of  iodin. 
Operation  3,  cut  off  a  piece  of  omentum  two  inches  wide  and  sufficiently  long  to  encircle 
the  entire  bowel.  After  scarifying  the  bowel  and  the  omental  graft  on  one  side,  the 
scarified  surfaces  were  brought  in  contact,  and  the  graft  fixed  in  its  place  by  two  fine  cat- 
gut sutures  passed  through  the  mesentery  and  both  ends  of  the  graft.  Animal  killed 
forty-eight  hours  after  operation.  All  plates  firmly  in  place  At  No.  i  adhesions  firm.  At 
No.  2  dark-brown  discoloration  of  surface  to  which  the  iodin  had  been  applied  ;  aggluti- 
nation over  the  whole  surface.  Under  hydrostatic  pressure  the  adhesions  first  gave  way 
between  the  two  plates  where  the  iodin  had  been  applied,  showing  conclusively  that 
chemic  irritation  of  serous  surface  does  not  hasten  the  adhesive  process,  while  it  may,  and 
probably  does,  expedite  the  definitive  healing.  At  No.  3  omental  graft  firmly  adherent 
to  the  entire  circumference  of  the  bowel  and  beginning  vascularization  of  the  graft 
around  its  margins. 

In  all  these  experiments  the  postmortem  examinations  showed 
no  evidences  of  diffuse  peritonitis.  In  most  of  the  cases  the  inflam- 
matory process  was  limited  to  the  portion  of  the  bowel  interposed 
between  the  plates.  Without  exception  the  adhesions  formed  were 
firmest,  and  the  definitive  healing-  was  initiated  first  where  scarifica- 
tion was  performed,  results  that  clearly  demonstrate  the  fact  that  the 
reparative  process  between  serous  surfaces  that  it  is  intended  to  unite 
is  hastened  by  traumatic  irritation.  Traumatic  irritation  by  scarifi- 
cation of  the  peritoneal  surface  with  the  point  of  an  aseptic  needle 
is  the  most  potent  means  to  provoke  a  circumscribed  plastic  periton- 
itis, and  is  followed  within  a  few  hours  by  a  copious  exudation  of 
plastic  lymph,  which,  like  a  cement  substance,  mechanically  agglu- 
tinates the  coaptated  serous  surfaces.  The  same  measure,  by  de- 
stroying the  continuity  of  the  nonvascular  layer  of  the  peritoneum, 
brings  at  once  in  contact  the  vascular  network  of  both  sides  of  the 
bowel,  and  opens  up  a  direct  route  for  the  new  vessels,  an  impor- 
tant element  in  the  rapid  healing  of  the  visceral  wounds.  Chemic 
irritants,  by  destroying  the  endothelial  layer  of  the  peritoneum, 
rather  retard  than  favor  early  adhesion  and  union  between  the  coap- 
tated bowels,  and  should  therefore  not  be  resorted  to  in  intestinal 
surgery  with  a  view  to  hasten  the  reparative  process. 

The  value  of  scarification  as  a  means  of  expediting  the  healing 
process  and  in  securing  firm  permanent  adhesions  can  no  longer  be 
questioned,  and  while  neither  essential,  nor  perhaps  even  necessary, 
in  intestinal  suturing,  it  never  does  harm  and  may  accomplish  much 


SUTURES.  8  I  3 

good.  It  should,  therefore,  never  be  neglected  in  abdominal  sur- 
gery when  the  operator  undertakes  to  fix  permanently,  by  broad 
adhesions  to  the  abdominal  wall,  any  of  the  pathologically  displaced 
organs. 

Needles  for  intestinal  suturing  must  be  round.  A  deUcate,  long, 
ordinary  sewing  needle  is  best  adapted  for  this  purpose.  Curved 
round  needles  must  be  kept  on  hand,  and  will  come  into  use  when 
the  intestinal  ends  to  be  united  can  not  be  brought  well  forward 
into  the  abdominal  incision  (Fig.  497). 

The  best  suturing  material  is  fine  aseptic  silk.  There  is  some 
advantage  in  using  iron-dyed  silk.  IMaunsell  is  very  partial  to 
horsehair,  carefully  selected  and  properh'  prepared.  This  material 
has  not  been  used  with  the  frequency  it  merits.  Horsehair  is  elastic 
to  some  extent,  and  causes  absolutely  no  irritation  in  the  tissues,  a 
matter  of  considerable  importance  in  using  the  seromuscular  stitch, 
which  comes  in  such  close  contact  with  the  mucous  membrane  and 
the  intestinal  contents,  full  of  pathogenic  microbes.  Some  surgeons 
rely  on  catgut,  but  there  is  no  special  adv^antage  in  the  use  of  ab- 
sorbable sutures  in  sewing  intestinal  wounds,  to  say  nothing  of  their 
greater  liability  to  give  way  and  to  become  a  direct  or  indirect  source 
of  infection. 

The  emergency  surgeon  should  be  familiar  with  the  different 
kinds  of  sutures  that  are  in  use  at  the  present  time  and  the  different 
methods  of  using  them,  and  he  must  be,  at  any  rate,  an  expert  in 
handling  the  needle  in  making  the  seromuscular  or  Lembert  stitch. 
Most  of  the  stitches  devised  since  the  time  of  Lembert  are  only 
modifications  of  his  stitch.  Lembert  was  the  first  one  who  taught 
that  in  closing  an  intestinal  wound  the  wound  margins  should  be 
inverted,  and  that  the  needle  should  not  penetrate  into  the  interior 
of  the  bowel,  so  that  when  the  sutures  are  tied,  the  serous  surfaces 
included  in  the  stitches  are  brought  and  held  in  contact.  Lembert 
emphasized  the  importance  of  including  only  the  peritoneum  in  the 
sutures,  and  hence,  for  a  long  time,  Lembert's  suture  has  been 
known  as  the  serous  or  peritoneal  suture,  in  contradistinction  to  the 
ancient  sutures,  which  included  all  the  coats  of  the  intestinal  wall. 
The  peritoneum  is  a  very  delicate  structure,  and  docs  not  offer  the 
necessary  resistance  to  give  the  sutures  a  safe  support,  and  prob- 
ably Lembert  himself  always  included  more  or  less  of  the  muscular 
coat  in  suturing  intestinal  wounds.  Even  the  older  text-books 
in.sist  on  including  in  the  Lembert  stitch  a  part  or  the  entire  middle 
tunic  of  the  intestinal  wall.  The  muscular  coat  itself  yields  under 
the  suture  if  the  intestine  is  distended,  and  surgeons  were  eager  to 
include  in  the  suture  a  firmer  and  more  resi.stant  tissue.  Cla.son 
has  shown,  by  his  anatomic  studies,  that  the  submuco.sa  of  the  small 
intestine  consi.sts  of  two  distinct  layers  of  connective-tissue  fibers, 
which,  according  to  the  ten.sion  of  the  intestine,  cro.ss  at  more  or  less 
acute  angles,  run  spirally  around  the  intestine,  and  make  the  sub- 
muco.sa much   like  the  "Indian  puzzle."     The.se  connective-ti.ssue 


8i4 


ENTERORRHAPHY. 


Fig.    502. — Lembert's    suture  :    a,    Serous    coat ; 
i>,  muscular  coat ;  c,  submucous  fibrous  layer. 


fibers  are  in  great  part  white  fibrous  tissue  bundles.  Halsted  was 
the  first  one  to  call  attention  to  this  important  tissue  in  connection 
with  the  intestinal  suture.  With  the  point  of  the  needle  these  firm 
connective-tissue  bundles    can   be   distinctly  felt,   and    a    sufficient 

number  of  the  fibers  are 
included  in  the  stitch  by 
lifting  them  up  on  the  point 
of  the  needle.  It  requires 
considerable  practice  on  the 
part  of  the  student  to  rec- 
ognize this  important  layer 
of  the  intestinal  wall  when 
he  first  begins  to  use  the 
needle.  Fresh  intestines 
from  dogs  or  pigs  furnish 
the  best  material  for  ac- 
quiring a  reliable  practical 
knowledge  oi  the  technic 
of  this  part  of  enteror- 
rhaphy.  The  suture  is  placed  so  close  to  the  mucous  membrane 
that  the  inexperienced,  untrained  physician,  in  his  endeavor  to 
secure  a  firm  hold  for  the  suture,  will  not  infrequently  penetrate 
the  mucous  membrane  or  its  glandular  appendages. 

Including  the  entire  thickness  of  the  intestinal  wall  is  attended 
by  much  risk  of  the  escape,  by  capillary  attraction,  of  septic  mate- 
rial into  the  peritoneal  cavity  in 
sufficient  quantity  and  virulence 
to  provoke  septic  peritonitis. 
Inclusion  in  the  stitch  of  one  or 
more  of  the  follicles  is  less  likely 
to  be  followed  by  such  an  im- 
mediate disastrous  consequence, 
but  it  opens  up  another  source 
of  danger  and  creates  an  obstacle 
to  a  speedy  healing  of  the  intes- 
tinal wound.  "  The  tearing  into 
the  crypts,  as  mentioned  by  Dr. 
Halsted,  suffices,  no  doubt,  to 
start  a  peritonitis.  But  it  also 
gives  the  crypt  a  chance  to  re- 
turn to  its  embryonic  type  and 
to  grow  out  of  its  proper  domain, 
thus  giving  an  additional  cause 
why  the  mucosa  should  not  be 
pierced.  It  may  possibly  be  that  these  cells,  when  once  fully 
liberated,  could  do  considerable  damage"  (F.  Mall).  The  Lembert 
stitch,  in  zvhatever  form  it  is  tised,  must  include  all  the  structures  of 
the  intestinal  wall  minus  the  mucosa. 


I^ig-  503' — Czerny- Lembert,  or  double 
intestinal,  suture.  The  deep  sutures  include 
all  the  coats  except  the  peritoneum. 


SUTURES. 


815 


-Cushing's    "right-angled"     con- 
tinuous suture. 


Another  rule  of  great  importance  bears  on  the  manner  in 
which  the  Lembert  stitch  should  be  tied  :  The  interrupted  Lembert 
stitch  must  be  tied  by  making  an  ordinary  square  knot,  and  only  with 
sufficient  firmness  to  approximate  and  hold  in  contact  the  serous  sur- 
faces, so  as  to  avoid  harmful 
linear  compressio?i.  Simple  as 
this  rule  may  appear,  it  is  cer- 
tain that  it  is  often  ignored 
and  that  more  frequently  the 
stitches  are  tied  too  tightly 
than  otherwise. 

The  stitches  should  be 
placed  sufficiently  close  to- 
gether to  render  the  line  of 
suturing  impermeable  to  gases 
and  fluids — that  is,  from  six 
to   eight  to  every  inch.      Too 

great  inversion  of  the  margins  of  the  wound  must  be  avoided,  as  it 
may  result  in  obstruction,  but  serous  surfaces  to  be  brought  in 
contact  must  be  wide  enough  for  a  speedy  and  sufficiently  broad 
union  to  take  place.  The  amount  of  tissue  included  in  each  stitch 
and  the  extent  of  inversion  of  the  wound  margins  must  be  deter- 
mined largely  by  the  size  of  the  wound  and  of  the  injured  intestine 
and  the  condition  of  the  tissues  included  in  the  sutures.  The  con- 
tinued  Lembert  stitch  is  frequently  employed  in  reinforcing  deep 

Czerny  stitches  and 
the  different  appli- 
ances used  as  sub- 
stitutes for  suturing. 
It  should  never  be 
used  in  place  of  the 
interrupted  suture 
where  one  row  of 
sutures  is  relied  upon 
in  closing  an  intes- 
tinal wound  or  in 
making  a  circular 
enterorrhaphy.  The 
continued  suture  can 
not  be  relied  upon  in 
regulating  the  coap- 
tating  force  with  the 
same  degree  of  ac- 
curacy as  when  the 
interrupted  sutures  are  used,  and  in  the  event  that  one  stitch  should 
give  way,  adjacent  stitches  are  often  loosened  sufficiently  to  give  rise 
to  extravasation  and  its  consequence,  peritonitis.  Ilalsted's  quilt 
suture  and  Cushing's  right-angled  suture  are  excellent  modifications 


Fig-  505- — Halsted's   mattress  suture  and  iiillatahle  hull 
for  circular  entcrorrhapliy. 


8i6 


ENTERORRHAPHY. 


Fig.  506. — Mitchell-Heamner  mesenteric  suture. 


of  Lembert's  seromuscular  stitch.  The  surgeon  of  hmited  experi- 
ence will,  however,  do  well  to  make  use  of  the  simplest  procedure 
and  rely  in  his  work  in  preference  on  the  Lembert  suture,  inter- 
rupted or  continued.      The   Mitchell-Heamner  mesenteric  suture  is 

a  very  important  aid  in 
circular  enterorrhaphy  in 
approximating  the  serous 
surfaces  on  the  mesenteric 
side. 

In  circular  enteror- 
rhaphy, if  time  permits 
two  rows  of  sutures,  deep 
and  superficial,  the  Czerny- 
Lembert  method  is  one 
that  offers  the  greatest 
safety  and  one  that  is  mastered  with  the  fewest  difficulties.  The 
deep,  or  Czeryty,  stitches  include  all  the  coats  of  the  intestinal  wall 
minus  the  peritoneum.  Each  stitch  includes  a  small  cone  of  tissue 
of  each  zvoiuid  margin,  the  base  of  which  is  directed  toward  the  line 
of  u7iion  (Fig.  503).  It  would  be  unsafe  to  include  the  peritoneum 
in  the  deep  row  of  sutures,  as  by  capillary  attraction  or  oozing 
intestinal  contents  might  find  a  way  between  the  two  rows  of 
sutures  or  enter  into  the  peritoneal  cavity.  The  inflatable  bulb 
and  Laplace's  anastomosis  forceps  render  valuable  aid  in  perform- 
ing intestinal  suturing.  One  of  the  first,  if  not  the  first,  inflatable 
bulb  for  circular  suturing 
was  devised  by  F.  Reder 
(Fig.  507). 

The  healing  of  intes- 
tinal wounds  has  been 
made  the  subject  of  very 
extended  investigation 
by  a  number  of  diligent 
experimenters,  and  the 
results  can  be  summar- 
ized from  the  conclu- 
sions drawn  from  his  own 
work  by  F.  Mall,  in  the 
paper  previously  referred 
to.  I  take  the  liberty  to 
make  use  of  a  few  of  the 
illustrations  that  accom- 
pany his  paper  and  that  exhibit  very  clearly  the  different  stages  of 
the  reparative  process  : 

"  I.   An  immediate  fibrinous  union  of  the  serous  surface. 
"  2.   A  destruction   of  the  protruding   parts  between    the  two 
flaps  of  mucosa.     This  destruction  is  brought  about  in  two  ways  : 


Fig.  507. — F.  Reder' s  inflatable  bulb. 


THE    REPARATIVE    PROCESS. 


817 


(a)  by  necrosis  and  (d)  the  destroying  power  of  those  crypts  tliat 
have  returned  to  their  embryonic  type. 

"  3.    Regeneration  of  the  mucous  membrane.      Soon  after  the 


Fig    508. — Repair  of  intestinal  wounds.      Suture  of  twenty-four  days  (X  9  times)  (after 
Mall  J :    C,  Granulation  tissue  ;   £.  G.  J'.,  regenerated  glands  and  cr)'pts  ;  SL,  stitch. 


utek 
Fig.  509  — Intestinal  suture  of  sixty  four  days  { /  9  times)  (after  Mall). 


intestine  is  sutured,  the  cut  ends  f)f  the  mucous  membrane  are  de- 
stroyed.      The   bases   rjf   the   crypts,    however,   seem    to    be    more 


52 


8i8 


ENTERORRHAPHY. 


resistant  and  soon  show  many  karyokinetic  figures  within  the 
epithelial  cells.  The  multiplication  of  cells  in  this  portion,  which 
is  probably  only  an  exaggeration  of  the  normal  process,  soon 
causes  this  layer  to  spread  in  all  directions.  These  cells  cover  the 
whole  surface  within  their  reach,  besides  sending  cystiform  invagi- 
nations into  the  tissue.  This  growth  continues  until  it  meets  cells 
from  the  opposite  side,  when,  of  course,  it  can  not  continue.  The 
■epithelial  covering  at  once  sends  invaginations  into  the  tissue,  which 
are  converted  into  crypts,  between  which  newly  formed  villi  arise 
and  grow  into  the  lumen  of  the  intestine.  If  the  conditions  are 
favorable,  the  mucous  membrane  is  fully  regenerated  at  the  end  of 

three  weeks. 

"  4.  Straightening 
of  the  suture.  Dur- 
ing the  fourth  week 
the  stitches  begin  to 
loosen  their  hold  in 
the  submucosa,  thus- 
allowing  the  intestine 
to  straighten  out. 
While  the  regenera- 
tion of  the  mucosa  is 
taking  place  the  sub- 
mucosa of  one  side  is 
being  united  by  fi- 
brous tissue  with  the 
submucosa  of  the 
other.  The  straight- 
ening of  the  suture 
now  allows  the  ends 
of  the  muscle  coats 
to  be  arranged  in  a 
straight  line,  besides 
placing  the  embryonic 
mucosa  under  a  greater  pressure,  thus  favoring  its  maturation. 
Before  the  straightening  is  complete  there  is  a  regeneration  of 
muscular  tissue,  most  marked  in  the  muscularis  mucosae. 

"The  stratum  fibrosum  is  most  resistant  and  does  not  begin  to 
regenerate  until  the  sixth  week.  Up  to  this  time  its  edge  is  marked 
by  a  sharp  border,  which,  during  the  sixth  week,  becomes  less  de- 
fined and  projects  across  the  line  of  suture. 

"  At  the  end  of  two  months  all  the  coats  are  fully  regenerated 
and  the  line  of  suture  can  hardly  be  made  out  microscopically, 
while  macroscopically  it  is  marked  by  a  thickening  of  the  intestinal 
walls." 

Lateral  Enterorrhaphy.— The  sewing  of  a  lateral  intestinal 
wound  presents  no  special  difficulties.  Usually  one  row  of  Lembert 
stitches  will  suffice.      If  the  injury  or  disease  has  resulted  in  any  con- 


Fig.  510. — Intestinal  suture  of  twenty-four  days 
(X  9  times)  (after  Mall):  S^.,  Projecting  submucosa; 
£.  G. ,  embryonic  glands. 


CIRCULAR    ENTERORRHAPHV, 


819 

siderable  defect  of  the  intestinal  wall,  the  wound  must  be  sutured 
transversely,  as  longitudinal  suturing  would  in  man\-  cases  result  in 
narrowing  of  the  bowel  to  an  extent  that  might'  cause  intestinal 
obstruction.  A  defect  of  an  inch  to  two  inches  on  the  con\ex  side 
of  the  bowel  can  be  sewed  transversely  without  causing  a  stenosis 
or  flexion  incompatible  with  the  free  passage  of  intestinal  contents. 
If  the  tissues  of  the  margins  of  the  defect  are  in  a  condition  that  has 
materially  damaged  their  resisting  power,  it  will  become  necessary 
to  make  a  double  row  of  Lembert  stitches — the  first  row  of  inter- 
rupted sutures,  the  second  of  the  continued  suture.  If  the  tissues 
can  not  be  relied  upon  in  furnishing  the  necessary  support  for  the 
sutures,  a  piece  of  the  omentum  should  be  fastened  over  the  hne  of 
suturing  with  a  few  superficial  stitches  as  an  additional  precaution 
against  perforation  and  extravasation. 

Circular  enterorrhaphy  consists  in  uniting,  by  suturing,  the 
two  ends  of  an  intestine  completely  severed.  Many  writers  and' sur- 
geons continue  to  call  this  method  of  restoring  the  continuity  of  the 
intestinal  canal  end=to=end  anastomosis,  which  certainly  gives  a 
wrong  impression  of  what  is  accomplished  by  the  suturing.  End- 
to-end  junction  of  the  intestine  is  done  quickly  and  safely  b}'  the 
Czerny-Lembert  double  suture.  The  deep  or  Czerny  stitches,  in- 
cluding all  the  tissues  except  the  peritoneum,  are  inserted  and  tied 
first  all  around,  where  they  are  buried  b\-  a  row  of  Lembert  stitches, 
interrupted  or  continuous.  Before  suturing  is  commenced  each  end 
of  the  bowel  should  be  beveled  at  the  expense  of  the  convex  side, 
as  by  doing  so  there  is  less  danger  of  the  sutures  causing  stenosis, 
and  the  liabilit\'  to  marginal  gangrene  on  the  convex  side  is  also 
diminished.  If  the  lumina  of  the  bowel  are  unequal  in  size,  as  is 
usually  the  case  in  making  resection  for  intestinal  ob.struction,  the 
obliquity  should  be  greatest  on  the  side  of  the  small  end.  I'he 
greatest  care  is  required  on  the  mesenteric  side,  as  it  is  here  where 
perforations  occur  most  frequently  in  consequence  of  a  faulty  tech- 
nic.  The  reflexion  of  the  peritoneum  on  each  side  at  the  mesenteric 
attachment  leaves  a  small  triangular  .space  containing  the  principal 
blood-vessels  that  supply  the  intestine  with  its  branches.  It  is  tiiis 
point  that  requires  special  attention. 

In  applying  the  Czerny  sutures  the  first  one  should  approximate 
the  two  .spaces.  The  .second  suture  is  j)laced  at  a  ])oint  opposite, 
on  the  convex  side,  .so  as  to  divide  the  wound  margins  at  once  into 
two  equal  halves.  The  remaining  sutures  are  then  inserted  and 
tied  in  such  a  way  that  the  wound  margins  arc  equally  tlistributed. 
The  ends  of  all  the  deep  sutures  should  be  cut  short  to  the  knot, 
as  all  these  sutures  are  intended  to  cut  their  way  through  the 
ti.ssucs,  being  cast  off  into  the  interior  of  the  intestine  and  elimi- 
nated with  the  fecal  discharges.  If  the  ends  are  left  unnecessarily 
long,  they  do  harm  by  retarding  the  elimination  of  the  sutuie  after 
it  has  accomplished  the  object  for  which  it  was  designed  ;  thej'  like- 
wise interfere  with  accurate  coaptation  of  the  .serous  surfaces  by  the 


820  ENTERORRHAPHY. 

second  row  of  sutures,  and,  finally,  by  capillary  attraction,  they  may 
become  the  medium  of  the  entrance  into  the  peritoneal  cavity  of 
pathogenic  bacteria  from  the  intestinal  canal. 

The  first  two  Lembert  stitches  are  inserted  and  tied  on  the 
mesenteric  side,  and  must  bring  accurately  together  the  peritoneal 
reflection  on  each  side.  This  is  a  very  important  step  in  circular 
enterorrhaphy,  and  one  that  is  frequently  ignored,  and,  if  so,  there 
is  the  greatest  danger  of  the  occurrence  of  a  perforation  at  the  little 
point  where  the  line  of  suturing  is  devoid  of  peritoneum.  The 
Mitchell-Heamner  stitch  (Fig.  506)  accomplishes  the  same  object  of 
turning  in  the  mesenteric  border,  but  as  it  transfixes  the  mesentery 
at  two  points,  it  might  endanger  the  circulation  in  the  included 
vessels,  more  especially  if  the  suture  should  be  tied  too  tightly.  Stu- 
dents and  practitioners  must  learn  to  correct  this  little  defect  of  the 
peritoneal  investment  of  the  intestines  by  giving  special  attention  to 
the  mesenteric  attachment  in  performing  circular  enterorrhaphy. 
All  Lembert  stitches  that  are  aseptic  and  remain  so  become  per- 
manently encysted  and  remain  harmless  in  the  tissues.  If  any  of 
these  stitches  include  the  mucous  surface  of  the  bowel,  even  to  a 
slight  extent,  such  a  favorable  disposal  is  not  to  be  expected  ;  on 
the  other  hand,  perforation,  abscess  formation,  and  peritonitis,  even 
at  a  late  day,  may  mar  the  result  of  the  operation. 

The  emergency  surgeon  must  become  accustomed  to  perform 
a  circular  enterorrhaphy  quickly  and  safely  without  any  special 
appliances  to  facilitate  the  insertion  and  tying  of  the  sutures. 

In  1892  F.  Reder,  of  Hannibal,  Mo.,  described  and  used  his  rub- 
ber bulb,  which  was  made  in  three  sizes  and  could  be  inflated  through 
a  small  rubber  tube  in  the  center.  Five  years  later  Halsted  de- 
scribed a  very  similar  bulb  in  his  paper  on  "  Inflated  Rubber  Cylin- 
ders for  Circular  Suture  of  the  Intestine"  ;  and  it  seems  that  some 
other  surgeons  have  made  very  similar  discoveries  before  and  after. 
Such  bulbs  may  prove  advantageous  if  the  bowel-ends  are  not  readily 
accessible  ;  otherwise  their  use  often  implies  an  unnecessary  loss  of 
time. 

Unquestionably,  the  most  valuable  aid  to  intestinal  suturing,  in 
making  either  an  anastomosis  or  a  circular  suture,  has  recently  been 
devised  by  Ernest  Laplace  (Fig.  494).  It  consists  of  a  pair  of  for- 
ceps of  very  ingenious  construction,  which  he  describes,  with  their 
use,  as  follows  : 

"  The  forceps  consists  of  two  parts,  which  are  really  hemo- 
static forceps,  curved  into  a  semicircle  on  each  side ;  only  held 
together  by  means  of  a  clasp,  they  open  as  two  rings.  They  are 
opened  within  the  intestine  and  serve  the  same  purpose  as  Senn's 
rings  or  any  other  ring  that  has  been  devised,  bringing  serous  mem- 
brane to  serous  membrane.  Accurate  suturing  is  the  operation  of 
the  present.  Therefore  if  these  forceps  are  within  the  gut  and  su- 
tures are  applied,  as  they  would  be  with  the  help  of  Senn's  rings,  it 
follows  that  sutures  are  introduced  all  around,  except  where  the  for- 


OMENTAL    GRAFTING.  821 

ceps  penetrate  the  parts  that  are  sutured.  The  suturing  being  done, 
the  forceps  are  released  by  loosening  the  clasp  and  then  withdrawing 
the  forceps  out  of  the  small  opening  :  first  one  half,  then  the  other, 
when  the  operation  is  finished  by  a  stitch  or  two.  This  forceps  will 
serve  for  the  operation  of  end-to-end  anastomosis  and  also  of  lateral 
anastomosis." 

The  inventor  demonstrated  the  use  of  his  instrument  before  the 
last  meeting  of  the  American  Surgical  Association,  and  every  mem- 
ber present  was  impressed  with  the  value  of  this  aid  in  all  kinds  of 
gastro-intestinal  work  requiring  suturing. 

Halsted's  quilt  stitch  (Fig.  505)  is  of  special  value  in  cases  in 
which  the  tissues  of  the  bow^el  at  the  seat  of  suturing  have  under- 
gone changes  that  have  diminished  their  firmness  and  resistance, 
caused  by  contusion,  inflammation,  or  distention.  It  is  in  such 
instances  that  the  surgeon  has  reason  to  fear  that,  notwithstanding 
the  suturing  has  been  done  with  the  utmost  care,  leakage  or  per- 
foration might  occur.  Nature  often  provides  a  safeguard  against 
such  occurrences  by  the  formation  of  adhesions  between  the  line  of 
suture  and  the  abdominal  wall  or  adjacent  viscera.  Such  adhesions 
often  correct  the  defects  of  the  mechanical  union  in  preventing 
diffuse  peritonitis,  but  not  infrequently  become  later  a  source  of 
danger  by  causing  intestinal  obstruction.  It  was  for  the  purpose 
of  preventing  such  occurrences  in  suturing  intestines  with  defective 
walls  that  I  made,  twelve  years  ago,  experiments  on  omental  graft- 
ing, being  desirous,  if  the  experiments  proved  successful,  of  furnish- 
ing the  line  of  suturing  with  a  band  of  living  tissue  that  would 
guard  against  extravasation  and  the  formation  of  parietal  and 
visceral  adhesions.  It  is  somewhat  strange  that  omental  grafting 
was  not  attempted  soon  after  Reverdin  and  Thiersch  demonstrated 
the  feasibility  of  transplantation  of  skin,  a  much  more  highly  organ- 
ized structure.  In  abdominal  surgery  the  operator  often  meets  with 
so  many  peritoneal  defects  that  should  be  covered  with  a  similar 
structure  that  omental  grafting,  if  shown  to  be  feasible,  certainly 
would  be  desirable.  The  conditions  for  grafting  in  the  abdominal 
cavity  are  vastly  more  favorable  than  on  the  surface  of  the  skin,  and 
the  results  of  my  experiments,  which  will  be  introduced  here,  leave 
no  further  doubt  concerning  the  practicability  and  advisability  of 
omental  grafting  in  cases  in  which,  after  intestinal  suturing,  lateral 
or  circular  leakage  is  feared,  as  well  as  in  cases  of  large  peritoneal 
defects,  for  the  purpo.se  f)f  preventing  dangerous  visceral  adhesions. 

Omental  Grafting. — Under  the  head  of  circular  enterorrhaphy 
mentif^n  is  made  of  transplantation  of  omental  flaps  after  uniting 
the  two  ends  of  the  bowel  by  suturing  or  invagination,  with  a 
view  of  securing  an  additional  safeguard  against  i)crforation  during 
the  process  of  repair.  A  number  of  ex|)criments  are  described 
where  the  procedure  was  practised  with  different  results.  After  a 
few  days  the  omental  flaps  were  found  firmly  adherent  and  vascular 
around  the  whole  circumference  of  the  bowel,  constituting  a  ring 


822  ENTERORRHAPHY. 

of  living  tissue  outside  the  line  of  suturing.  In  all  these  cases  the 
proximal  end  of  the  flap  remained  in  connection  with  the  omentum, 
and  care  was  taken  to  cut  the  flap  in  such  a  manner  that  some 
vessel  of  considerable  size  should  furnish  the  necessary  vascular 
supply.  I  was  well  aware  that  plausible  objections  could  be  entered 
against  this  method,  in  that  the  connecting  bridge  between  the 
bowel  and  the  omentum  might  become  subsequently  a  cause  of 
intestinal  obstruction  by  making  traction  upon  the  bowel,  thus  caus- 
ing a  flexion,  or  by  becoming  a  band  of  constriction  for  some  loop 
of  intestine.  For  the  purpose  of  obviating  such  remote  conse- 
quences another  procedure  was  practised  which  can  be  properly 
designated  as  omental  grafting.  It  is  a  well-known  fact  that  im- 
plantations of  aseptic  substances  into  the  peritoneal  cavity  have  fre- 
quently been  done  without  any  immediate  or  remote  ill  effects,  and 
there  was  every  reason  to  expect  that  a  large,  completely  detached 
aseptic  omental  graft,  in  an  aseptic  abdominal  cavity,  would  be  well 
tolerated,  and  would  soon  become  adherent  to  the  subjacent  peri- 
toneal surface,  and  thus  afford  an  additional  safeguard  against  perfora- 
tion and  the  disastrous  consecutive  result — perforative  peritonitis — 
during  the  time  required  for  the  healing  of  the  intestinal  wound. 
In  the  following  experiments  the  grafts  used  were  from  one  and  a 
half  to  two  inches  in  width,  and  of  sufficient  length  to  encircle  the 
bowel  completely.  The  free  ends  were  made  to  project  a  few  lines 
beyond  the  mesenteric  attachment,  and  were  fixed  by  two  fine  cat- 
gut sutures,  each  of  which  embraced  the  corresponding  angles  of 
the  graft  and  the  mesentery.  The  stitches  were  made  in  the  direc- 
tion of  the  mesenteric  vessels,  so  that  in  tying  no  vessel  should  be 
included  in  the  suture.  In  these  experiments  dogs  were  used 
exclusively. 

Experiment  io6. — Three  pieces  of  omentum,  two  inches  wide  and  sufficiently  long 
to  encircle  the  bowel,  were  completely  detached  and  grafted  as  follows  : 

1.  Graft  simply  laid  over  the  bowel  corresponding  to  the  lower  portion  of  the  ileum 
and  fastened  in  its  place  on  mesenteric  side  by  two  fine  catgut  sutures. 

2.  Serous  surface  of  bowel  about  six  inches  higher  up  scarified  and  graft  applied  to 
this  surface  and  fixed  in  the  same  manner. 

3.  About  six  inches  still  higher  up  bowel  treated  in  the  same  way,  and  one  of  the 
serous  surfaces  of  the  graft  also  freely  scarified. 

The  graft  was  scarified  on'  the  side  which  was  to  be  brought  in  contact  with  the 
bowel.  Fixation  of  graft  by  two  catgut  sutures  on  mesenteric  side.  Animal  killed  thirty- 
six  hours  after  operation.  All  the  grafts  adherent,  slightly  contracting  the  bowel  at  the 
three  different  places.  On  separating  the  adhesions  the  subjacent  serous  surface  was  very 
vascular  and  denuded  of  its  endothelial  layer.  Firmness  of  adhesions  increases  in  pro- 
portion to  the  extent  of  scarification  done,  being  least  firm  at  No.  I,  firmer  at  No.  2,  and 
firmest  at  No.  3,  where  both  coaptated  serous  surfaces  had  been  scarified.  At  Nos.  2 
and  3  the  plastic  lymph  was  freely  supplied  with  new  blood-vessels.  The  vascularization 
was  most  conspicuous  on  the  mesenteric  side. 

Experiment  107. — Two  omental  grafts  planted  around  the  ileum  in  the  same  man- 
ner as  described  above.  At  No.  1  both  the  bowel  and  the  inner  side  of  the  graft  were 
scarified;  at  No.  2,  only  the  serous  surface  of  the  bowel.  Animal  killed  forty-three 
hours  after  operation.  Stump  of  omentum  adherent  to  abdominal  wound  and  intestines. 
No  peritonitis.  At  No.  i  graft  firmly  adherent  over  the  entire  extent.  A  slight  extrava- 
sation of  blood  between  the  graft  and  the  bowel.  Beginning  vascularization  of  inter- 
posed plastic  lymph.  At  No.  2  also  firm  adhesions  and  beginning  vascularizadon  of  the 
plastic  exudadon.  Both  of  the  grafts  appeared  to  be  stained  with  the  coloring  material  of 
the  blood.  ^ 


OMENTAL    GRAFTING.  823 

Experiment  108. — Planting  of  two  omental  grafts  around  the  ileum,  about  eight 
inches  apart.  At  No.  i  both  the  bowel  and  one  side  of  the  omental  graft  were  scarifurd. 
At  No.  2  only  the  serous  surface  of  the  bowel  was  treated  in  this  manner.  Animal  killed 
six  days  after  the  operation.  Both  grafts  firmly  adherent  throughout  and  freely  supj)lied 
with  blood-vessels,  the  largest  of  the  new  vessels  being  on  the  mesenteric  side.  The 
omental  stump  adherent  to  the  portion  of  bowel  between  the  grafts,  where  a  flexion  has 
been  made  from  this  cause. 

Experiment  109. — In  this  experiment  omental  grafting  was  done  at  two  points 
around  the  lower  portion  of  the  ileum.  At  one  point  the  serous  surfaces  were  left  intact ; 
at  the  other  both  the  peritoneal  surface  of  the  bowel  and  the  omental  graft  were  freely 
scarified.  Animal  remained  perfectly  well  and  was  killed  eight  days  after  operation. 
No  signs  of  peritonitis.  Both  grafts  formed  a  thin  vascular  layer  around  the  entire  cir- 
cumference of  the  bowel  and  firmly  and  evenly  united  throughout.  Vascularization  was 
more  marked  where  scarification  had  been  done.  On  attempting  to  separate  the  grafts  it 
was  difficult  to  find  and  define  the  line  of  union  between  the  omentum  and  the  underlying 
bowel,  as  the  union  was  very  intimate  and  firm. 

In  all  these  experiment.s  the  grafts  retained  their  vitality,  and  in 
a  few  hours  became  firmly  adherent  to  the  intestinal  surface  with 
which  they  had  been  brought  in  contact.  Scarification  of  the  serous 
surface  has  also  been  found  in  these  experiments  an  exceedingly 
valuable  measure  in  hastening  the  process  of  adhesion,  granulation, 
and  vascularization.  By  planting  grafts  side  by  side,  with  and  with- 
out scarification,  it  was  possible  to  determine  with  accuracy  the  bene- 
ficial influence  exerted  by  this  procedure  in  favoring  the  reparative 
process,  and  without  a  single  exception  it  was  observed  that  where 
scarification  was  done,  the  adhesions  were  firmer  and  vascularization 
more  advanced.  The  postmortem  examinations  appeared  to  demon- 
strate that  the  firmness  of  the  adhesions  and  the  degree  of  vascular- 
ization were  in  direct  proportion  to  the  extent  of  traumatic  irritation 
of  the  peritoneum,  being  always  most  marked  in  cases  where  both 
the  bowel  and  the  under  surface  of  the  graft  were  scarified,  and  least 
where  intact  peritoneal  surfaces  were  brought  into  apj)osition.  As 
soon  as  the  omental  grafts  were  cut  off  from  the  omentum  they  were 
placed  in  a  I  :  2000  solution  of  corrosive  sublimate,  kept  at  the  tem- 
perature of  the  body  in  order  to  .secure  for  the  graft  a  perfectly  asep- 
tic condition,  until  everything  was  in  readiness  for  the  transfer  of  the 
graft  to  its  new  location.  A  warm  .saline  .solution  will  probably  be 
better  adapted  for  immersion  of  the  omental  graft.  Hcfore  planting 
the  graft  it  was  carefully  dried  by  pressing  it  between  gauze  or 
.sponges  wrung  out  of  the  same  solution.  The  .scarifications  of  the 
serous  surfaces  should  be  made  only  sufficiently  deep  to  give  ri.se  to 
a  very  slight  oozing,  as  when  hemorrhage  is  more  profuse  there  is 
danger  of  the  formation  of  a  clot  between  tlie  graft  and  the  bowel, 
which,  if  it  does  not  ultimately  prevent  union  between  the  coaptated 
surfaces,  must  neces.sarily  interfere  with  the  formation  of  early  and 
firm  adhesions.  Omental  grafting  can  not  fail  in  becoming  an  estab- 
lished procedure  in  many  abdominal  operations.  After  sutiMing  a 
large  wound  of  the  stomach  or  intestines,  a  .strip  of  omentiun  should 
be  laid  over  the  wound  and  fastened  in  its  place  by  a  few  catgut 
sutures.  After  circular  enterorrhajihy  in  cases  in  which  the  tissues 
of  the  bowel  have  fjeen  damaged  by  injmy  or  disease,  the  f)i)eration 
shf)uld  be  finished  by  cf;vering  the  circular  wound   by  an  omental 


824 


ENTERORRHAPHY. 


graft  about  two  inches  wide,  which  should  be  fixed  in  its  place  by 
two  catgut  sutures  passed  through  both  ends  of  the  graft  and  the 
mesentery.  Omental  grafting  should  also  be  resorted  to  in  repairing 
peritoneal  defects  in  visceral  injuries  of  the  abdominal  organs,  and  in 
covering  large  stumps  after  ovariotomy  or  hysterectomy,  where  the 
pedicle  is  treated  by  the  intra-abdominal  method. 

Scarification  of  the  serous  surfaces  included  in  the  sutures  and 
omental  transplantation  and  grafting  are  modern  surgical  resources 
that  hasten  the  process  of  repair  and  materially  diminish  the  risk 
of  extravasation.  These  means  should  be  resorted  to  when,  owing 
to  the  damaged  condition  of  the  tissues,  the  sutures  can  not  be  fully 
relied  upon.      The  experiments  described  have  shown  conclusively 

that  scarification  of  the 
peritoneum  at  the  seat  of 
coaptation  hastens  the  for- 
mation of  adhesions  and 
the  definitive  healing  of 
the  intestinal  wound. 

Omental  grafts,  from 
one  to  two  inches  in  width, 
and  sufficiently  long  to  en- 
circle the  bowel  completely, 
retain  their  vitality,  become 
firmly  adherent  in  from 
twelve  to  eighteen  hours, 
and  are  freely  supplied 
with  blood-vessels  in  from 
eighteen  to  forty -eight 
hours. 

Omental  transplanta- 
tion or  omental  grafting 
should  be  done  in  every 
circular  resection  or  sutur- 
ing of  large  wounds  of  the 
stomach  or  intestines  in  all 
cases  requiring  an  addi- 
tional security,  as  this  procedure  favors  healing  of  the  visceral 
wound  and  affords  an  additional  protection  against  perforation. 

The  most  important  and  practical  modification  of  circular 
enterorrhaphy,  as  ordinarily  practised,  has  been  described  by  H. 
Widenham  Maunsell.  Bring  the  ends  of  the  bowel  together  with 
two  temporary  sutures  passed  through  all  the  coats  of  the  intestine. 
The  long  ends  of  these  sutures  are  left  intact.  One  is  placed  at  the 
mesenteric  attachment  and  the  other  exactly  opposite.  These  tem- 
porary sutures  secure  the  complete  peritoneal  covering  of  the  mes- 
enteric attachment  of  both  segments,  help  to  maintain  the  proper 
relative  position  and  accurate  coaptation  of  the  two  cut  ends,  and 
facilitate  their  subsequent  invagination  through  the  opening  in  the 


Fig.  5 1 1 .— Maunseir  s  method  of  circular  en- 
terorrhaphy :  A,  Longitudinal  section  (about  an 
inch  and  a  half  long)  with  tenotomy  knife  of  that 
portion  of  the  larger  segment  of  bowel  that  is 
opposite  to  its  mesenteric  attachment.  This  open- 
ing should  be  made  about  an  inch  from  the  severed 
end  of  the  larger  segment  of  bowel ;  its  length  de- 
pends on  the  size  of  the  intestine  to  be  invaginated. 
In  perfoiTning  this  part  of  the  operation  pinch  up 
the  coats  of  the  intestine  between  the  finger  and 
thumb  and  divide  with  a  tenotomy  knife  or  pair 
of  scissors. 


Fig.  512. — Maunsell's  method  for  longitudinal 
section  of  intestine  :  a.  Peritoneal  coat ;  b,  muscular 
coat  ;  c,  mucous  coat  ;  </,  temporary  sutures  passed 
into  the  bowel  and  out  through  the  longitudinal  slit 
made  in  the  larger  segment  of  bowel ;  e,  mesentery. 


OMENTAL    GRAFTING.  825 

larger  segment  of  the  gut.  A  slit  is  made  on  the  convex  side  of 
the  larger  segment,  an  inch  or  so  from  the  cut  end,  and  large 
enough  for  the  invaginated  ends  of  the  divided  bowel  to  be  dragged 
through  by  the  long  ends  of  the  temporary  sutures.  When  Ihcy 
are  accurately  sewn  to- 
gether all  around,  they  /^  ^^ 
may  be  pulled  back  into 
their  normal  position.  <?^ 
The  edges  of  the  longi-  JnTa 
tudinal  slit  made  in  the  <3e, 
bowel  should  be  well 
turned  in  and  brought 
together  with  a  con- 
tinuous suture  passed 
through  the  peritoneal 
and  muscular  coats  only. 
By  this  simple  device  the 
perfect  union  by  suture 
of  a  complete  transverse 
section  of  the  bowel, 
with  its  circumferential  peritoneal  surfaces  in  exact  position,  and 
all  the  knots  of  the  sutures  on  the  inside,  can  be  accompli.shed. 
From  figure  513  it  may  be  seen  that  the  peritoneal  surfaces  are  in 
accurate  apposition  all  around.  While  an  assistant  holds  the  ends 
of  the  temporary  sutures,  the  surgeon  passes  a  long,  fine,  straight 
needle,  armed  with  a  stout  horsehair  or  very  fine  silkworm  gut, 
through  both  sides  of  the  bowel,  taking  a  good  hold  (quarter  of  an 

inch)  of  all  the 
coats.  The  suture 
is  then  hooked  up 
from  the  center 
of  the  invaginated 
gut,  divided,  and 
tied  on  both  sides. 
///  this  way  ttventy 
snt7ires  can  be 
placed  rapidly  in 
position  with  ten 
passages  of  the 
needle  (see  Fig. 
514).  The  tem- 
j)orary  sutures  arc 
nf)w  cut  short,  and 
the  bowel  is  then  pulled  back.  The  longitudinal  slit  is  then  clo.scd 
in  the  usual  manner,  completing  the  operation. 

Maunsell's  method  has  been  favorably  received  by  the  profession 
and  has  yicjrjed  most  excellent  results.  The  use  of  horsehair  in 
place  of  silk  is  undoubtedly  a  great  advantage  in  performing  this 


'■'K  5 '3- — Ixingitudinal  .section  of  intestine,  showing 
the  relative  position  of  tiie  diff(!rent  layers  of  the  bowel  in- 
vaginated at  the  longiluflinal  slit. 


826 


ENTERORRHAPHY. 


operation,  as  the  danger  from  leakage  by  capillary  attraction  is  much 
less  and  the  elasticity  of  the  sutures  hastens  their  elimination. 

Murphy  Button  as  a  Substitute  for  Circular  Enterorrhaphy. 
— Of  all  the  appliances  as  a  substitute  for  suturing  of  intestinal 
wounds,  the  Murphy  button  has  been  used  most  extensively  and 
has  yielded  the  best  results.  The  utility  of  this  device  is  most 
apparent  in  retaining  the  continuity  of  the  bowel  after  resection, 
when  the  operation  has  to  be  finished  as  rapidly  as  possible.  A 
full  set  of  buttons  of  faultless  construction  should  be  kept  on  hand. 
The  manner  of  using  the  button  is  so  well  shown  (Fig.  516)  that  a 
description  would  be  superfluous. 

Frank's  coupler  of  decalcified  bone  will  undoubtedly  come 
into  more  general  use  after  a  more  extensive  experience. 

Intestinal  Anastomosis  and  Lateral  Implantation. — There 
are  conditions  that  give  rise  to  intestinal  obstruction  that  can  not  be 


Fig.  514.— Maunsell's  method.  In- 
vaginated  intestine,  showing  the  two  peri- 
toneal surfaces  in  juxtaposition  all  around  : 
a.  Needle  passed  through  both  sides  of  the 
bowel,  including  all  the  coats — introduc- 
ing two  sutures  with  one  passage  of  the 
needle. 


^ig-  515- — Maunsell's  method,  intes- 
tine reduced  :  a.  Line  marking  junction  of 
both  ends  of  bowel,  the  peritoneum  well 
turned  in  and  the  sutures  and  knots  all  in- 
side of  the  bowel,  making  an  almost  invisi- 
ble air-  and  water-tight  joint ;  b,  longitu- 
dinal slit  in  bowel,  sewn  up  with  contin- 
uous suture  ;  c,  sutures  in  the  mesentery  ; 
seldom  necessary  to  insert  more  than  one 
or  two. 


removed  without  imminent  immediate  risk  to  life  ;  or,  after  resec- 
tion, the  two  bowel-ends  can  not  be  joined  by  suturing.  In  such 
cases  modern  surgery  comes  to  our  aid  in  restoring  the  continuity 
of  the  intestinal  canal  by  making  an  intestinal  anastomosis  by  lat- 
eral apposition  or  implantation.  The  experiments  related  below 
were  made  prior  to  1887,  and  most  of  them  before  I  accidentally 
found  an  account  of  two  cases  of  anastomosis  by  Maisonneuve  in 
one  of  the  old  volumes  of  "Rust's  Magazine."  The  operation 
had  been  entirely  forgotten,  and  was  never  mentioned  in  the  current 
medical  literature  until  it  was  revived  by  my  experimental  work. 

Intestinal  Anastomosis. — By  an  intestinal  anastomosis  is  un- 
derstood a  condition  of  the  intestinal  canal  where,  on  account  of 
an  obstruction  or  complete  occlusion,  the  intestinal  contents  are 
directed  into  a  segment  of  the  bowel  below  the  seat  of  obstruction 
or  occlusion  through  a  fistulous  opening  between  the  bowel  above 
and  below  the  seat  of  partial  or  complete  occlusion.      The  idea  of 


INTESTINAL    ANASTOMOSIS. 


!27 


establishing  such  a  communication  between  the  bowel  above  and 
below  the  seat  of  obstruction  originated  with  Maisonneuve,  who, 
without  testing  the  new  procedure  first  on  animals,  operated  on  two 
cases,  but  as  the  result  in  each  case  was  fatal,  he  seems  to  have 
become  discouraged  and  abandoned  the  operation,  and  never  pub- 
lished the  communication  on  this  subject  which  he  had  in  prepara- 
tion. In  the  Sur- 
gical Society  of 
Paris,  his  proposi- 
tion met  with  vio- 
lent opposition 
from  his  contem- 
poraries, who  ar- 
gued that  the  ex- 
cluded portion  of 
the  intestine  would 
become  the  seat  of 
fecal  accumulation, 
which,  even  if  the 
operation  was  a 
success,  would 
subsequently  de- 
stroy the  life  of 
the  patient.  The 
s  u  b j  e  c  t  was  re- 
vived in  1863  by 
Hacken,  who,  un- 
der the  direction 
of  Adelmann,  made 
some  experiments 
on  dogs.  For  a 
long  time  the  op- 
eration was  com- 
pletely forgotten, 
until  E.  Hahn,  of 
Berlin,  very  re- 
cently alluded  to 
it  again  in  com- 
menting on  his 
two  ca.scs  of  ex- 
cision of  the  colon 
where  circular  entcrorrhaj)hy  could  not  he  ])crf(jinu'(l,  and  where 
an  artificial  anus  was  established.  Both  patients  recovered  from 
the  operation,  but  all  attempts  to  close  the  preternatural  opening 
proved  futile.  The  results  of  my  experiments  have  shown  conclu- 
sively that  the  fear  of  accumulation  of  feces  in  the  excluded  portion  of 
the  intestine — that  is,  the  intervenin;:^  portion  containing  tin:  seat  of 
obstruction  and  extending  on  each  side  as  far  as  the  new  opining  by 


Fig.  516.  —  Resection  of  intestine:  a,  />,  Tiie  two  lialves 
of  the  button  ;  r,  tiie  two  portions  clamped  togetiier ;  </,  intro- 
duction of  tiie  sutures  for  holdinfj  each  Iialf  of  tlie  l)utton  in 
place.  The  lower  fifjure  shows  the  c()in|)lfted  union  of  the 
intestine  by  the  Murpjiy  button  ;  the  slip  in  the  mesentery  has 
tjeen  closed  by  linear  union  (after  Zuckerkandl). 


828  ENTERORRHAPHY. 

which  the  anastomosis  has  been  estabhshed — is  unfounded.  If  this 
objection  can  be  laid  aside,  it  becomes  evident  that  the  operation  of 
making  an  intestinal  anastomosis  has  a  great  future,  and  will  soon 
become  the  recognized  procedure  in  the  treatment  of  intestinal 
obstruction,  and  as  a  substitute  for  circular  suturing  in  some  forms 
of  injuries  or  diseases  of  the  intestines  that  require  excision. 

The  first  experiments  were  performed  by  making  an  incision  an 
inch  and  a  half  to  two  inches  in  length  through  the  convex  surface 
of  each  bowel,  and  by  suturing  the  wounds  together  by  Czerny- 
Lembert  sutures.  The  results  soon  showed  that  the  operation  was 
attended  by  the  same  dangers  as  suturing  after  circular  resection — 
that  is,  gangrene  of  the  margins  of  the  bowel  and  perforation.  Dr. 
M.  E.  Connel,  Superintendent  of  the  Milwaukee  County  Hospital, 
suggested  the  use  of  perforated  plates  for  making  the  lateral  appo- 
sition in  place  of  suturing.  A  few  crude  experiments  were  made 
with  perforated  discs  of  lead,  wood,  gutta-percha,  and  leather,  and 
the  results  soon  satisfied  us  of  the  expediency  and  greater  safety  of 
uniting  the  intestines  in  this  manner.  Although  the  first  experi- 
ments were  very  imperfect  and  faulty  in  technic,  almost  every  animal 
recovered.  In  the  first  experiments  no  needles  were  used.  Around 
the  oval  perforation  four  catgut  or  silk  sutures  were  tied  ;  a  slit  was 
made  in  the  bowel  on  the  convex  side,  parallel  with  its  axis  and 
large  enough  to  permit  the  passage  of  a  plate  about  an  inch  in 
width  and  about  two  and  one-half  inches  in  length.  After  making 
the  incision  and  introducing  the  plate  above  and  below  the  seat  of 
obstruction,  the  two  wounds  were  brought  into  apposition  and  the 
corresponding  strings  tied  together  with  sufficient  iirmness  to  bring 
the  flattened  surfaces  into  accurate  coaptation.  The  threads  were 
cut  short,  and  the  ends  pushed  inward  out  of  sight.  Experience 
showed  that  although  the  apposition  was  good,  a  tendency  was 
observed  on  the  part  of  the  margins  of  the  wound  to  evert  on 
account  of  the  bulging  of  the  mucous  membrane.  For  this  reason 
the  operation  was  modified  by  arming  the  lateral  threads  with  a 
needle  with  which  the  margin  of  the  incision  about  the  middle  of 
the  wound  was  transfixed.  This  proved  a  step  in  the  right  direction, 
as  the  lateral  sutures  completely  prevented  eversion  of  the  margins 
of  the  wound,  at  the  same  time  fixed  the  plates  in  their  position,  and, 
further,  at  once  transformed  the  longitudinal  sHt  into  an  oval  foramen 
of  sufficient  size  for  the  free  passage  of  intestinal  contents.  After 
many  trials  with  different  kinds  of  materials  for  the  plates  the  con- 
clusion was  reached  that  decalcified  or  partially  decalcified  bone- 
plates,  preserved  after  the  decalcification  in  pure  alcohol,  served  the 
best  purpose. 

Directions  for  Preparing  Bone-plates. — The  compact  layer 
of  an  ox's  femur  or  tibia  is  cut  with  a  fine  saw  into  oval  plates,  one- 
fourth  of  an  inch  in  thickness,  two  and  one-half  to  three  inches  in 
length,  and  an  inch  in  width.  The  plates  are  then  decalcified  in  a 
lo  per  cent,  solution  of  hydrochloric  acid,  changed  every  twenty- 


JEJUNO-ILEOSTOMY.  820 

four  hours  until  they  have  become  sufficiently  softened  to  be  bent 
in  any  direction  without  fracturing.  After  decalcification  they 
are  washed  by  letting  water  flow  over  them  for  from  three  to  six 
hours,  so  as  to  remove  the  acid.  The  plates  are  then  covered  with 
porous  paper  and  compressed  between  two  pieces  of  tin  until  they 
are  perfectly  dry.  If,  during  the  process  of  drying,  the  plates  are 
not  compressed  between  two  smooth  surfaces,  they  become  dis- 
torted by  warping.  The  hardened  plates  are  next  drillefl  several 
times  in  a  straight  line  in  the  center,  and  the  openings  enlarged  and 
connected  with  a  file,  until  the  perforation  is  Sg  inch  in  length  and 
about  Is  to  ^(^  inch  in  width.  The  sharp  margins  of  the  plate  and 
perforations  are  removed  with  a  file.  With  a  fine  drill  the  four  per- 
forations for  the  sutures  are  made  near  the  margin  of  the  oblong 
perforation — one  at  each  end  and  one  at  each  side.  For  preserva- 
tion the  plates  are  kept  in  absolute  alcohol.  When  the  plates  are 
to  be  used,  they  are  washed  in  a  2  per  cent,  solution  of  carbolic 
acid,  and  the  threads  or  sutures  attached  by  threading  two  fine 
sewing  needles,  each  with  a  piece  of  aseptic  silk  twenty-four  inches  in 
length,  which  are  tied  together.  The  threads  are  then  fastened  to 
the  surface  of  the  plate  by  another  thread,  passing  through  the  per- 
forations in  the  shape  of  a  loop,  and  fastened  at  the  back. 

Anastomosis  between  the  stomach  and  small  intestines  is  called 
gastro-enterostomy  ;  between  the  jejunum  and  ileum,  jejuno-ileos- 
tomy  ;  between  the  ileum  and  ileum,  ileo-ileostomy ;  between  ileum 
and  cecum,  ileotyphlostomy  ;  between  ileum  and  colon,  ileocolos- 
tomy  ;  between  ileum  and  sigmoid  flexure,  ileosigmoidostomy  ;  be- 
tween colon  and  colon,  colocolostomy  ;  between  sigmoid  flexure  and 
rectum,  sigmoidorectostomy  ;  between  colon  and  rectum,  colorec- 
tostomy. 

The  experiments  were  made  to  relieve  an  artificially  produced 
intestinal  ob.struction,  a  fact  that  may  account  to  some  e.xtent  for 
the  high  mortality  of  the  operations.  The  very  high  death-rate 
from  the  operations  done  by  suturing  was  unquestionably  largely 
due  to  defective  technic  and  inexperience. 

Jejuno-ileostomy. — In  this  operation  some  form  of  intestinal 
obstruction,  either  complete,  by  division  of  the  bowel  and  closure 
of  both  ends,  or  partial,  by  making  a  volvulus,  invagination,  or 
flexion  in  the  vicinity  of  the  juncture  of  the  jejunum  with  the  ileum, 
was  fir.st  established  and  then  an  intestinal  anastomosis  made  by 
establishing  a  communication  between  the  bowel  above  and 
below  the  obstruction.  I^efore  the  peiforatetl  a])i)ro.\imation  discs 
were  used  this  was  accomplished  by  making  an  inci.sion  an 
inch  and  a  half  or  two  inches  in  length  through  the  convex- 
surface  of  the  bowel  above  and  i^elow  the  ob.struction.  and 
uniting  the  wounds  by  a  double  row  of  sutures.  An  operation 
of  this  kind  usually  lasted  over  an  hour,  while  the  rapid  operation 
of  coa[)tation  by  jjerforated  di.sc.'--  sel(lf)m  took  more  than  filteen 
minutes. 


830  ENTERORRHAPHY. 

Jejuno=ileostomy  by  Suturing. 

Experiment  56. — Large  cat.  Invagination  of  ileum  into  ileum  in  a  downward 
direction,  and  fixation  of  intussusceptum  to  neck  of  intussuscipiens  by  two  fine  catgut 
sutures,  to  prevent  spontaneous  reduction.  Intestinal  anastomosis  by  establishing  an 
opening  an  inch  in  length  ;  suturing  by  Czerny-Lembert  method.  The  animal  never 
recovered  from  the  shock  of  the  operation,  and  died  in  less  than  twenty-four  hours. 
Length  of  intussusceptum  two  inches,  which,  after  the  removal  of  the  sutures,  could  not 
be  reduced  by  traction,  as  the  bowel  was  firmly  constricted  by  the  neck  of  the  intussus- 
cipiens and  recent  adhesions  had  formed.      No  peritonitis  ;  suturing  found  perfect. 

Experiment  57. — Dog,  weight  sixty-five  pounds.  Intestinal  obstruction  by  mak- 
ing acute  flexions  in  upper  portion  of  ileum,  and  fixation  of  loops  of  intestine  by  fine 
catgut  sutures.  Intestinal  anastomosis  between  jejunum  and  ileum  by  incision  and 
double  suturing.  The  animal  died  on  third  day,  with  symptoms  of  perforative  periton- 
itis. On  close  examination,  one  of  the  superficial  approximation  sutures  had  been 
passed  through  the  whole  thickness  of  the  wall  of  the  bowel,  and  it  was  here  that  per- 
foration had  taken  place.      Recent  diffuse  peritonitis. 

Experiment  58. — Dog,  weight  seventeen  pounds.  Descending  invagination  of 
ileum  into  ileum  ;  length  of  intussusceptum  three  inches  ;  fixation  by  two  catgut  sutures. 
Formation  of  intestinal  anastomosis  between  the  bowel  above  and  below  the  invagina- 
tion by  incision  and  double  suturing.  Animal  died  on  third  day  with  symptoms  of  per- 
forative peritonitis.  Abdominal  wound  not  united.  Adhesions  at  point  of  operation 
quite  firm.  Diffuse  general  peritonitis  from  a  perforation  that  had  been  made  by  a  sharp 
fragment  of  bone  above  the  new  opening.      Intussusceptum  not  gangrenous. 

Experiment  59. — Dog,  weight,  twenty-three  pounds.  Intestinal  obstruction  was 
made  by  producing  a  volvulus  in  the  upper  part  of  the  ileum.  Restoration  of  continuity 
of  intestinal  canal  by  making  a  jejuno-ileostomy  by  lateral  apposition  and  double  sutur- 
ing. Day  after  operation  intestinal  discharges  were  bloody  ;  after  this  time,  normal. 
Animal  in  perfect  health  when  killed,  sixty-seven  days  after  operation.  The  volvulus 
was  found  in  same  condition  as  after  operation  ;  the  intestinal  loop  was  empty,  atrophied, 
and  adherent  to  adjacent  loops  of  intestine.  Bowel  above  seat  of  obstruction  and  as  far 
as  the  new  opening  empty.  Intestinal  tract  above  and  below  the  obstruction  presented  no 
indication  of  the  presence  of  an  obstruction.  New  opening  oval  in  shape  and  as  large  as 
the  lumen  of  the  bowel  at  that  point. 

Experiment  60. — Large  Maltese  cat.  Intestinal  obstruction  by  making  two  flexions 
in  ileum,  about  eighteen  inches  apart,  after  this  portion  had  been  cleared  of  its  contents. 
Flexions  made  by  doubling  the  bowel  toward  its  convex  side  and  fixing  it  in  this  position 
by  fine  catgut  sutures.  Jejuno-ileostomy  by  lateral  apposition  and  suturing.  Vomiting 
day  after  operation  ;  stools  scanty  the  first  few  days,  and  later  complete  obstruction. 
Died  nineteen  days  after  operation.  Wound  completely  united  ;  no  general  peritonitis  ; 
flexions  remained ;  bowel  between  them  contained  a  slight  amount  of  fecal  matter. 
Bowel  some  distance  above  the  new  opening  very  much  dilated,  pointing  to  obstruction 
above  new  opening.  On  tracing  the  intestinal  canal  from  above  downward  this  obstruc- 
tion is  seen  to  consist  in  acute  flexion  of  the  bowel  by  firm  and  extensive  adhesions.  New 
opening  sufficiently  large  to  admit  the  tip  of  the  index-finger,  and  around  the  margins  of 
the  opening  most  of  the  deep  sutures  remain  attached. 

Experiment  61. — Large  cat.  Obstruction  made  by  two  flexions  in  the  ileum,  their 
apices  being  united  by  catgut  sutures.  Intestinal  anastomosis  made  by  a  jejuno-ileostomy. 
For  eleven  days  the  animal  remained  in  good  condition,  when  symptoms  of  perforative 
peritonitis  manifested  tliemselves,  and  death  ensued  two  days  later.  External  portion 
of  wound  not  united.  Numerous  omental  and  intestinal  adhesions.  Flexions  retained 
and  their  apices  adherent  to  each  other  by  firm  band  of  adhesion.  Excluded  portions 
above  and  below  the  obstruction  empty.  Two  small  perforations  at  point  of  suturing  on 
anterior  surface  of  bowel  ;  remaining  portion  of  wound  firmly  united.  New  opening 
sufficiendy  large  to  admit  tip  of  index-finger.      Death  from  perforative  peritonitis. 

Experiment  62. — Large  Newfoundland  dog.  Descending  invagination  of  ileum 
into  ileum  to  the  extent  of  six  inches  ;  fixation  of  intussusceptum  by  two  catgut  sutures. 
Permeability  of  intestinal  canal  restored  by  making  a  jejuno-ileostomy  ;  wounds  united 
by  a  double  row  of  sutures.  Intestinal  discharges  normal  throughout.  No  rise  in  tem- 
perature. When  killed  on  the  twentieth  day,  general  condition  as  good  as  before  oper- 
aiion.  Abdominal  wound  completely  united  ;  no  peritonitis  ;  omentum  adherent  at  site 
of  operation.  Invagination  had  reduced  itself,  and  its  location  was  marked  by  an  acute 
flexion  caused  by  extensive  adhesions.  No  accumulation  of  intestinal  contents  in  ex- 
cluded portions.  The  new  opening  at  least  two  inches  in  length,  a  few  of  the  deep 
sutures  remaining  attached  to  its  margins.  This  opening  was  partially  obstructed  by  a 
mass  of  hair  and  fragments  of  bone.      On  passing  a  stream  of  water  from  above  downward 


JEJUNO-ILEOSTOMY    BY    PLATES. 


831 


the  fluid  passed  dirough  an  opening  in  the  center  of  this  mass  into  the  lower  portion  of 
the  Ileum,  but  not  through  the  portion  that  was  invaginated.  Alter  this  ma^s  was  re- 
moved the  fluid  was  found  to  pass  through  the  portion  that  was  invaginated  as  well  as 
through  the  new  opening. 

The  many  failures  which  attended  jejuno-ileostomy  and  ileo- 
ileostomy  by  lateral  apposition  and  suturing  led  to  the  use  of  per- 
forated approximation  discs.  A  great  contrast  was  observed  in  the 
animals  operated  upon  by  these  two  methods.  The  operation  by 
suturing  required  usually  more  than  an  hour,  and  almost  all  the 
animals  showed  more  or  less  symptoms  of  shock  after  its  comple- 
tion, and  not  a  few  succumbed  to  its  immediate  effects,  while  the 
operation  by  approximation  plates  could  always  be  finished  within 
twenty  minutes  ;  consequentl\-  the  animals  never  suffered  seriously 
from  the  immediate  effects  of  the  operation.  The  first  experiments 
were  made  somewhat  carelessly  and  with  crude  material,  and  vet  it 
was  observed  that  the  healing  process  progressed  more  favorably 
and  was  accomplished  in  a  shorter  time  than  after  suturing.  The 
approximation  discs  brought  into  uninterrupted  contact  large  serous 
surfaces  without  impairing  the  vascular  supply ;  at  the  same  time 
they  secured  for  the  parts  destined  to  become  united  an  essential 
condition  for  rapid  wound  healing — rest — by  serving  the  useful  pur- 
pose of  splints. 

Experiment  63.— Dog,  weight  fifteen  pounds.  Ileum  was  completely  divided  at 
Its  junction  with  the  jejunum,  and  both  ends  of  the  bowel  closed  by  invagination  and 
three  stitches  of  the  continued  suture.  An  incision  was  made  on  convex  side  of  bowel, 
about  two  inches  from  the  closed  ends,  and  a  heavy  perforated  lead  plate,  to  which  six 
catgut  sutures  were  fastened  around  the  oval  perforation,  was  introduced  into  the  lumen 
of  the  bowel  of  each  closed  end,  all  the  catgut  sutures  being  brought  out  through  the 
incision.  The  two  wounds  were  brought  opposite  each  other  and  the  six  sutures  tied. 
The  serous  surfaces  of  the  two  intestines  over  a  surface  corresponding  to  the  size  of  the 
lead  discs  were  thus  brought  into  accurate  apposition.  The  sutures  were  cut  short,  and 
the  ends  buried  as  deeply  as  possible.  The  condition  of  the  animal  remained  excellent 
until  the  tirne  of  killing,  seventy-five  days  after  operation.  Omentum  adherent  to  wound  ; 
large  intestine  distended  with  normal  feces.  Bowel  above  and  below  point  of  operation 
normal  in  size  and  structure.  New  o[)ening  between  ileum  and  jejunum  large  enough 
to  admit  the  little  finger  to  second  joint.  Bowels  firmly  united  by  a  broad  surface.  Above 
the  communicating  opening  a  double  flexion  of  the  bowel  was  found  that  apparently  had 
done  no  harm. 

Exi'KRiMENT  64. — Dog,  weight  eighteen  pounds.  Operation  done  in  the  same  man- 
ner as  in  the  last  experiment,  only  that  instead  of  lead  the  discs  were  made  of  sole 
leather,  and  the  sutures  used  were  linen  in  place  of  catgut.  For  a  few  days  the  tempera- 
ture was  higher  than  normal  and  appetite  diminished.  After  fourth  day  the  animal 
apijeared  to  be  in  excellent  condition  and  remained  .so  for  three  weeks,  when  the  appe- 
tite failed  and  occasional  attacks  (>(  vomiting  .set  in.  The.se  symptoms  remained  more  or 
less  prominent  until  the  time  of  killing,  ihirty-nine  days  after  operation.  Omentum 
adherent  to  abdominal  wound  ;  extensive  intestinal  adhesions  at  site  of  o|i(iation  ;  union 
between  intestines  perf<;ct.  On  incising  the  bowel  it  was  found  that  the  plates  had 
sloughed  through  and  had  passed  along  the  distal  ])ortion  of  the  bowel,  leaving  an  open- 
ing the  size  of  the  jilales,  the  margins  of  which  had  almost  comjiletely  cicatrized.  The 
two  leather  plates,  still  held  tf)gether  by  the  linen  sutures,  were  found  three  (e(;t  lower 
down  in  the  ileum,  where  they  had  become  embedded  in  a  mass  of  hair,  straw,  nnd 
fecal  matter,  and  f|uite  firmly  impacted,  causing  complete  obslruclion  of  the  bowel. 
'Ihe  intestine  above  the  seal  of  obstruction  was  enormously  dilated,  while  below  the 
seat  of  imi^action  it  was  empty  and  contracted.  Large  intestine  likewise  empty  and 
contracted.  'Ihe  cause  of  the  illness  was  evidently  due  to  intestinal  ol).slruction,  pro- 
duced by  the  impaction  of  the  large  enterolith,  in  the  center  of  which  the  leather  discs 
were  found. 

Kxi'ERlMKNT  65.  — Dog,    weight    ten    pounds.       In   this   instance  the  bowel    was 


832 


ENTERORRHAPHY. 


divided  near  the  junction  of  the  jejunum  with  the  ileum,  both  ends  closed,  and  its  con- 
tinuity established  by  incising  the  convex  surface  of  both  ends  and  approximating  the 
wounds  by  two  perforated  bone-plates  tied  together  by  silk  ligatures.  The  animal  died 
fourteen  days  after  operation.  During  the  last  few  days  symptoms  of  intestinal  obstruc- 
tion were  present.  Abdominal  wound  completely  united.  Numerous  intestinal  adhe- 
sions at  site  of  operation.  Bone-plates  still  in  situ  and  firmly  fixed.  On  proximal  side 
perforation  of  bone-plates  completely  closed  by  hair  and  fragments  of  bone,  giving  rise 
to  complete  intestinal  obstruction.  The  bowel  above  this  point  was  greatly  dilated, 
while  on  distal  side  it  was  empty  and  contracted.  Adhesions  between  the  two  intestinal 
surfaces  included  by  the  bone-plates  firm.  Intestinal  obstruction  by  a  mechanical  arrest 
of  portion  of  the  intestinal  contents  above  the  proximal  plate  caused  death  before  a  more 
efficient  communication  could  be  established  by  sloughing  through  of  the  bone-plates. 

Experiment  66. — Dog,  weight  thirty  pounds.  Ileo-ileostomy  by  dividing  the 
ileum  near  its  center,  closing  both  sides,  and,  after  incising  both  ends  on  convex  surface, 
brought  wounds  in  apposition  by  perforated  plates  of  cross-grained  walnut  wood,  which 
were  tied  together  with  silk  sutures.  The  dog  remained  in  perfect  health  and  was  killed 
eighteen  days  after  operation.  External  wound  completely  united.  Plates  had  become 
detached,  leaving  a  communicating  opening  two  inches  in  length.  Blind  ends  of  bowel 
empty  ;  no  trace  of  plates  could  be  found. 

Experiment  67. — Dog,  weight  twenty-four  pounds.  Double  ileo-ileostomy.  Ileum 
divided  transversely  five  inches  above  ileocecal  region,  and  both  ends  closed  by  invagina- 
tion and  three  stitches  of  the  continued  suture.  Lower  and  upper  ends  of  bowel  were 
again  brought  into  communication  by  incision  on  convex  side  and  lateral  apposition  of 
wounds  by  means  of  perforated  approximation  plates  of  decalcified  bone,  hardened  in  alco- 
hol. The  plates  were  fastened  together  by  four  silk  sutures,  the  threads  being  brought  out 
of  the  incision,  tied,  and  cut  short.  Above  this  point  a  loop  of  the  ileum  was  made  by 
bringing  the  convex  surfaces  into  apposition  after  incision  at  two  points,  and  introducing 
perforated  gutta-percha  plates,  which  were  retained  in  place  by  four  silk  sutures.  No 
fever  or  symptoms  of  obstruction  followed  the  operation.  Animal  killed  thirteen  days 
later.  External  wound  firmly  united.  No  evidences  of  peritonitis  or  intestinal  obstruc- 
tion. First  operation  left  a  communicating  opening  large  enough  to  admit  the  little  fin- 
ger. The  silk  ligatures  that  had  become  detached  from  the  plates  had  embedded  them- 
selves. The  decalcified  bone-plates  had  disappeared,  and  no  trace  of  them  could  be 
found  in  any  portion  of  the  intestinal  canal  lower  down.  The  second  operation  was 
thirty  inches  higher  up.  Gutta-percha  plates  remained  in  situ,  although  somewhat 
loosened  by  the  gradual  disappearance  of  the  intervening  tissues  by  pressure  atrophy. 
Adhesions  between  the  two  surfaces  of  the  bowel  firm  and  extending  a  little  beyond  the 
line  of  approximation.  The  perforation  in  the  proximal  plate  almost  completely  closed 
by  an  accumulation  of  hair.      The  entire  ileum  normal  in  size  and  appearance. 

Experiment  68. — Dog,  weight  fifty-four  pounds.  Transverse  section  of  ileum 
thirty  inches  above  the  ileocecal  region,  and  closure  of  both  ends  in  the  usual  manner. 
The  two  closed  ends  were  overlapped  four  inches  and  brought  into  communication  by 
two  longitudinal  openings,  which  were  approximated  by  being  buttoned  together  with  a 
shuttle-shaped  button,  nearly  one  and  one-half  inches  in  length,  the  sides  being  lead  plates 
and  the  shaft  a  rubber  tube  through  which  the  anastomosis  was  established  at  once.  As 
the  margins  of  the  intestinal  wounds  showed  a  tendency  to  evert,  a  fine  catgut  suture  was 
inserted  on  each  side  embracing  only  the  peritoneal  coat.  Only  for  two  or  three  days 
after  the  operation  did  the  dog  not  appear  to  be  well.  Killed  twenty-three  days  after 
operation.  Omentum  adherent  to  abdominal  wound,  which  was  firmly  united.  Omental 
adhesions  to  intestine  at  site  of  operation.  Intestinal  anastomosis  thirty  inches  above  the 
ileocecal  valve.  Proximal  blind  end  of  bowel  five  inches  in  length,  adherent  to  distal 
end,  considerably  dilated,  and  contained  fragments  of  bone  and  other  crude  substances. 
Approximation  button  in  situ  and  quite  firmly  fixed.  A  fragment  of  bone  partly  fills  the 
lumen  of  the  rubber  tube.  Coaptated  peritoneal  surfaces  firmly  adherent.  The  obstruc- 
tion of  the  communicating  tube  had  given  rise  to  dilatation  of  the  bowel  above  the  point 
to  twice  its  natural  size,  while  below  the  seat  of  partial  obstruction  the  intestine  appeared 
empty  and  contracted. 

Experiment  69.— Small  dog.  In  this  experiment  the  ileo-ileostomy  was  made  by 
lateral  apposition  by  perforated  approximation  plates  of  partially  decalcified  bone  tied 
together  by  four  catgut  sutures.  The  lateral  sutures  were  passed  through  the  margins  of 
the  wottnd  near  its  border,  a  modification  of  the  usual  procedure  that  not  only  fixed  the 
plates  firmly  in  their  places,  but  also  prevented  ectropion  of  the  mucous  membrane,  and 
insured  free  patency  of  the  new  opening  by  retracting  the  margins  of  the  wound  so  that 
the  longitudinal  slit  is  at  once  transformed  into  an  oval  shape.  The  animal  showed  no 
unfavorable  symptoms,  and  was  killed  twenty-nine  days  after  operation.  Dog  well  nour- 
ished.   External  wound  united.    Omentum  adherent  to  wound  and  intestines.    The  prox- 


ILEOCOLOSTOMY.  835 

imal  blind  end  of  bowel  contained  one  of  the  bone-plates,  which  showed  signs  of  soften- 
ing and  disintegration.  The  bone-plate  in  the  distal  end  had  been  passed  with  feces 
previously.  The  new  opening  perfect  and  sufficiently  large  to  equal  in  size  the  lumen  of 
the  bowel. 

Experiment  70. — Dog,  weight  twelve  pounds.  Made  ileo-ileostomy  the  same  as 
in  the  last  experiment,  using  decalcified,  perforated  bone-plates,  which  were  tied  together 
with  four  catgut  sutures,  the  lateral  ones  being  passed  through  the  margins  of  that  wound. 
An  omental  flap  was  used  to  cover  the  sides  of  the  bowel  where  approximation  had  been 
made.  This  flap  was  retained  by  two  fine  catgut  sutures.  No  unfavorable  symptoms. 
Animal  killed  twenty-three  days  after  operation.  Omentum  adherent  to  distal  blind  end. 
Omental  flap  in  position  and  firmly  adherent.  Site  of  operation  fourteen  inches  above 
ileocecal  region.  Both  bone-plates  had  disappeared  and  no  trace  of  them  could  be  found. 
Some  hair  had  collected  in  the  blind  proximal  end.  New  opening  large  enough  to  admit 
the  index-finger. 

Jejuno-ileostomy  and  ileo-ileostomy  by  apposition  with  decalcified 
perforated  bone-plates  in  cases  of  complete  obstruction  of  the  bowel 
artificially  produced  is  an  operation  almost  devoid  of  danger.  Par- 
tially or  completely  decalcified  bone-plates  hardened  in  alcohol 
remain  firm  for  a  sufficient  length  of  time  to  answer  the  purpose  of 
retentive  measures  until  firm  adhesions  have  formed  between  the 
serous  surfaces  held  in  approximation  by  them,  until  it  was  ascer- 
tained by  experiment  that  the  plates  would  undergo  softening  and 
disintegration  in  the  course  of  a  few  days,  catgut  sutures  were  used 
to  hold  them  in  place  with  the  expectation  that  the  plates  would 
become  detached  and  escape  with  the  intestinal  contents  as  soon  as 
the  sutures  would  give  way.  Experience,  however,  has  shown  that 
aseptic  silk  threads  are  preferable  to  catgut,  as  they  can  be  tied 
with  greater  accuracy  and  the  knots  will  never  become  loosened, 
while  the  approximation  discs  disappear  completely  by  softening 
and  disintegration  in  a  few  days.  Approximation  plates  of  unab- 
sorbable  material,  as  lead,  wood,  leather,  bone,  and  gutta-percha, 
fastened  together  by  .silk  or  linen  sutures,  remain  /;/  situ  until  the 
interposed  tissues  disappear  by  pressure  atrophy,  and  the  opening 
that  results  corresponds  in  size  to  the  dimensions  of  the  plates.  In 
the  fir.st  experiments  the  plates  were  tied  together  by  six  sutures, 
but  it  was  found  that  four  sutures  answered  the  same  purpose. 
As  a  rule,  the  plates  were  about  two  and  one-half  inches  in  length, 
and  their  width  corresponded  to  one-third  of  the  circumference  of 
the  bowel.  The  greatest  advantage  to  be  found  in  the  method 
of  restoring  the  continuity  of  the  intestinal  canal  by  lateral  ai)po- 
sition  by  approximation  discs  consists  in  the  fact  that  the  point  of 
contact  is  always  made  on  the  convex  surface  of  the  intestines,  so 
that  the  means  employed  to  secure  coaptation  do  not  interfere  with 
the  blood  supply  from  the  mesenteric  vessels.  As  this  method 
requires  much  le.ss  time  than  any  form  of  circular  enterorrhaphy  and 
has  been  followed,  almost  without  exception,  by  recovery,  it  recom- 
mends itself  strongly  as  a  substitute  for  the  latter  procedure  in 
many  cases  where  loss  of  time  constitutes  an  important  factor  in 
the  i.ssue  of  the  ca.se,  or  where,  from  other  causes,  circular  suturing 
appears  impossible  or  impracticable. 

Ileocolostomy.— As  the  ileocecal  region  is  frecjuently  the  scat 
53 


834  ENTERORRHAPHY. 

of  intestinal  obstruction,  it  becomes  desirable  to  devise  some  defi- 
nite plan  of  operative  treatment  in  cases  where  the  cause  of  ob- 
struction is  not  amenable  to  removal,  with  a  view  to  establishing 
the  continuity  of  the  intestinal  canal,  thus  avoiding  the  'necessity  of 
resorting  to  the  formation  of  an  artificial  anus.  To  accompHsh 
this  object  two  distinct  methods  were  followed  :  (i)  Division  of  the 
ileum,  with  closure  of  distal  and  implantation  of  proximal  end  into 
colon.  (2)  Division  of  ileum,  closure  of  both  ends,  and  lateral 
apposition  of  proximal  end  with  colon,  and  the  formation  of  an 
intestinal  anastomosis  by  suturing  or  approximation  discs. 

Ileocolostomy  by  Implantation. 

Experiment  71. — Dog,  weight  thirty-eight  pounds.  Intestinal  anastomosis  by- 
implantation  of  the  ileum  into  colon.  The  ileum  was  divided  transversely  just  above  the 
ileocecal  region,  and  the  distal  end  closed  by  invagination  and  three  stitches  of  the  con- 
tinued suture,  and  dropped  back  into  the  abdominal  cavity.  A  longitudinal  incision,  in 
size  corresponding  to  the  lumen  of  the  ileum,  was  made  in  the  ascending  colon  at  a  point 
directly  opposite  the  mesenteric  attachment,  and  the  proximal  end  of  the  ileum  was  then 
fixed  in  this  opening  by  Czerny-Lembert  sutures.  Only  slight  febrile  reaction  followed 
the  operation.  The  appetite  remained  good,  and  the  discharges  from  the  bowels  were 
normal.  The  animal  was  in  excellent  condition  when  killed,  thirty-three  days  after 
operation.  Few  circumscribed  omental  adhesions  to  abdominal  wound,  which  was  com- 
pletely closed.  Peripheral  portion  of  ileum  presents  a  conic  appearance,  and  was  found 
adherent  to,  and  of  the  same  length  as,  the  appendix  vermiformis.  Implantation  had 
been  done  about  the  middle  of  the  colon.  Union  at  point  of  suturing  perfect ;  apparently 
no  interruption  of  continuity  of  peritoneal  surface.  The  new  opening  into  colon  a  little 
smaller  than  the  lumen  of  the  ileum.  Around  the  margins  of  this  opening,  which  some- 
what resembled  the  ileocecal  valve,  six  of  the  deep  silk  sutures  remained  attached.  Above 
the  new  opening  the  colon  and  the  cecum  were  found  empty  and  somewhat  atrophic. 
Lower  portion  of  the  ileum  and  of  the  colon  below  the  new  opening  appears  normal  in  size 
and  structure. 

In  the  remaining  experiments  the  implantation  was  made  by  lining  the  proximal  end 
of  the  ileum  with  a  narrow  flexible  rubber  ring,  which  was  retained  in  place  by  a  con- 
tinued catgut  suture,  embracing  the  free  margin  of  the  bowel  and  the  lower  margin  of  the 
rubber  ring.  The  implantation  was  made  by  two  catgut  sutures  (invagination  sutures), 
threaded  each  by  two  needles  and  passed  at  opposite  points  from  within  outward  through 
the  upper  margin  of  the  ring  and  the  entire  thickness  of  the  bowel,  while  the  needles 
were  passed  through  only  the  serous  and  muscular  coats  of  the  colon.  After  both  sutures 
were  in  place  gentle  traction  upon  all  of  the  ends  brought  the  end  of  the  ileum  into  the 
incision  in  the  colon,  and  the  walls  of  the  colon  were  drawn  over  the  end  of  the  ileum  to 
the  points  where  the  needles  emerged  from  the  ileum,  making  really  a  limited  invagina- 
tion. When  in  proper  position,  the  serous  surfaces  of  the  colon  and  ileum  over  a  surface 
corresponding  to  the  width  of  the  rubber  ring  were  in  accurate  coaptation  after  the  two 
sutures  were  tied.  Only  in  exceptional  cases  was  it  found  necessary  to  apply  one  or  two 
additional  superficial  coaptation  sutures.  As  in  circular  enterorrhaphy,  so  in  these  cases, 
the  elastic  pressure  on  part  of  the  rubber  ring  rendered  fnaterial  assistance  in  maintaining 
accurate  coaptation,  while  at  the  same  time  it  secured  rest  for  the  sutured  parts,  and  kept 
the  new  opening  freely  patent  for  the  escape  of  intestinal  contents  into  the  colon.  This 
operation  did  not  require  one-fourth  of  the  time  consumed  in  making  an  implantation  by 
Czerny-Lembert  sutures. 

Experiment  72. — Dog,  weight  fifty  pounds.  Division  of  ileum  eight  inches  above 
ileocecal  region  ;  distal  end  closed  by  invagination  and  three  stitches  of  the  continued 
suture.  Proximal  end  lined  with  rubber  ring  and  implanted  into  incision  of  ascending 
colon  by  two  catgut  invagination  sutures.  The  dog  did  not  appear  to  do  well  after  the 
operation,  and  died  on  the  fifth  day.  Abdominal  wound  not  united.  Partial  separation 
of  implanted  bowel  and  diffuse  septic  peritonitis  from  perforation. 

Experiment  73. — Dog.  weight  thirty-five  pounds.  Ileum  divided  twelve  inches 
above  ileocecal  region,  distal  end  closed,  and  proximal  end  lined  with  flexible  rubber 
ring  and  implanted  into  an  incision  in  the  transverse  colon  and  retained  by  two  invagina- 
tion sutures  of  catgut.  An  omental  flap  an  inch  and  a  half  in  width  was  placed  over  the 
junction  of  the  two  intestines  and  fixed  in  its  place  by  two  catgut  sutures.  No  unfavor- 
able symptoms  after  operation.      Animal,  when  killed,  eighteen  days  later,  in  excellent 


ILEOCOLOSTOMV    BV    LATERAL    APPOSITION.  835 

condition.  Omentum  adherent  to  abdominal  wound,  which  was  firmly  united.  Omental 
flap  adherent  all  round.  Colon  above  new  opening  ten  inches  in  length,  completely 
empty,  contracted,  and  atrophic.  New  opening  oval  in  outline  and  as  large  as  the  lumen 
of  the  ileum. 

Experiment  74. — Dog,  weight  sixteen  pounds.  Division  of  ileum,  closure  of  distal 
end,  and  implantation  of  proximal  end  into  an  incision  of  the  colon  by  rubber  ring  and  two 
invagination  sutures  of  catgut.  As  the  inverted  portions  of  the  colon  showed  a  tendency 
to  evert,  two  additional  retaining  sutures  of  fine  catgut  were  used,  which  secured  perfect 
coaptation  throughout.  An  omental  flap  was  laid  over  the  junction  of  the  intestines  and 
fixed  in  its  place  by  one  catgut  suture.  The  dog  remained  in  good  condition,  appetite 
unimpaired,  and  discharges  from  bowels  nomial.  Killed  thirteen  days  after  operation. 
Abdominal  wound  firmly  united.  Omentum  adherent  to  wound.  A  number  of  adhe- 
sions between  coils  of  intestine.  Ileum  soinewhat  dilated  above  the  new  opening. 
Omental  flap  in  place  and  adherent.  Union  between  ileum  and  colon  perfect.  A  long, 
sharp  fragment  of  bone  was  found  lodged  just  above  the  new  ojiening,  its  lower  end  par- 
tially occluding  its  lumen.  The  dilatation  of  the  lower  portion  of  the  ileum  was  evidently 
due  to  partial  obstruction  from  the  presence  of  the  foreign  body  in  the  new  opening. 

Experiment  75. — Dog,  medium  size.  Section  of  ileum  two  feet  above  the  ileo- 
cecal region  ;  closure  of  distal  end  in  the  usual  manner  ;  implantation  of  proximal  end 
into  colon  by  rubber  ring  and  two  invagination  sutures  of  catgut.  IS'o  omental  flap.  Ani- 
mal remained  well  and  was  killed  forty-three  days  after  operation.  Omentum  adherent 
to  abdominal  wound.  Distal  end  of  ileum  conic  in  shape,  the  extremity  presenting  a 
cup-shaped  depression  which  was  filled  with  cicatricial  material.  Omentum  adherent  at 
ileocecal  region  and  at  site  of  operation.  Union  between  the  bowels  perfect,  and  their 
serous  surfaces  appeared  to  be  continuous  over  the  line  of  junction.  The  new  opening 
from  the  colon  admitted  the  little  finger,  and  was  surrounded  by  a  prominent  ridge  of 
mucous  membrane  that  resembled  the  ileocecal  valve. 

Experiment  76. — Dog,  weight  fourteen  pounds.  Division  of  ileum  a  few  inches 
above  ileocecal  valve  ;  distal  end  clo.sed  by  invagination  and  three  stitches  of  continued 
suture.  Implantation  of  proximal  end  into  colon  by  rubber  ring  and  two  catgut  invagi- 
nation sutures.  Over  the  junction  of  the  two  intestines  an  omental  flap  was  placed, 
which  was  retained  by  a  catgut  suture.  The  animal  showed  no  unfavorable  symptoms, 
and  was  killed  twenty-three  days  after  operation.  Omental  flap  retained  and  firmly  adhe- 
rent throughout.  Point  of  implantation  three  inches  above  cecum  ;  union  between  the 
two  intestines  firm  throughout.  New  opening  corresponded  in  size  to  the  lumen  of  the 
ileum,  and  was  surrounded  by  a  prominent  ridge  of  mucous  membrane  that  appeared  to 
be  derived  from  the  invaginated  portion  of  the  ileum. 

Experiment  77.— Ileum  divided  a  few  inches  above  ileocecal  region,  and,  after 
closure  of  distal  and  proximal  ends,  was  imjilanted  into  the  colon  iii  the  usual  manner  by 
means  of  rubber  ring  and  two  invagination  sutures  of  catgut.  Animal  died  on  the  third 
day  after  operation.  Wound  partially  united  ;  a  considerable  quantity  of  serosanguino- 
leiit  fluid  in  the  abdominal  cavity.  Ileum  almost  completely  separated  from  colon,  and 
the  pfjrtion  that  had  been  invaginated  showed  .signs  of  gangrene.  Rubber  ring  had  dis- 
appeared ;  death  from  perforative  peritonitis.  In  this  case  there  was  reason  to  believe  that 
the  rubber  ring  that  was  used  was  too  large,  and  that  the  gangrene  and  separation  were 
due  to  injurious  pressure. 

Ileocolostomy  by  Lateral  Apposition. — Anastomosi.s  by  tlii.s 
method  wa.s  made  after  producing  an  intestinal  ob.struction  of  some 
kind  at  or  near  the  ileocecal  region,  and  then  by  bringing  the  ileum 
above  the  .seat  of  obstruction,  in  communication  with  the  colon 
below  the  point  of  obstruction  by  making  an  inci.sion  an  inch  and  a 
half  to  two  inche-s  in  length  in  both  intestines  at  a  point  opposite 
the  mesenteric  attachments,  and  uniting  the  wounds  either  by  a 
double  row  of  sutures  or  by  perforated  decalcified  bone  discs.  1  he 
first  experiments  were  all  made  by  suturing,  but,  as  in  a  circular 
enterorrhaphy,  it  was  found  by  experience  that  ))crforation  not  infre- 
quently occurred  along  the  track  of  one  of  the  sutures,  in  .some 
instances  .several  days  after  the  operation,  at  a  time  when  union  had 
taken  place  by  firm  adhesions.  These  unfavorable  results  led  to  the 
u.se  of  the  approximation  discs. 


836 


ENTERORRHAPHY. 


Experiment  78. — Dog,  weight  twenty-five  pounds.  The  ileum  was  withdrawn 
from  the  abdomen  through  an  incision  in  the  linea  alba,  and,  a  loop  being  emptied  of 
its  contents,  acute  flexion  was  made  just  .above  the  ileocecal  region  by  approximating  the 
serous  surfaces  of  the  convex  side  for  an  inch  and  a  half  by  five  catgut  sutures.  Two 
longitudinal  incisions  of  equal  size  were  made,  one  in  the  ileum,  six  inches  above  the 
flexion,  and  the  other  in  the  ascending  colon,  three  inches  above  the  cecum.  The  vis- 
ceral wounds  were  carefully  united  by  Czerny-Lembert  sutures,  using  silk  for  the  deep 
interrupted  sutures,  and  fine  catgut  for  the  superficial  continued  sutures.  No  untoward 
symptoms  were  observed  after  the  operation  ;  appetite  remained  unimpaired,  and  fecal 
discharges  were  normal.  The  dog  was  killed  thirty-seven  days  after  operation.  Animal 
well  nourished.  No  evidences  of  peritonitis.  Bowel  above  point  of  obstruction  nearly 
empty,  and  somewhat  contracted  as  far  as  the  new  opening.  Flexion  permeable  to  a 
stream  of  water.  Slight  omental  adhesions  to  bowel  at  site  of  operation  ;  union  firm 
throughout.  Lumina  of  nonexcluded  portion  of  bowel  normal  in  size  above  and  below 
the  flexion.  Serous  surfaces  at  point  of  junction  appeared  perfect  and  continuous.  On 
slitting  open  the  colon  opposite  the  new  opening,  its  outlines  were  seen  to  be  marked 
by  a  prominent  ridge  of  mucous  membrane  to  which  a  number  of  the  deep  sutures  re- 
mained attached.  The  opening  was  large  enough  to  admit  the  tip  of  the  middle  finger. 
The  excluded  portions  of  the  colon  and  the  cecum  were  somewhat  contracted  and  atro- 
phic and  contained  only  a  very  small  quantity  of  fecal  matter. 

Experiment  79. — Medium-sized  cat.  About  two  inches  of  the  ileum  were  invagi- 
nated  into  the  colon  through  the  ileocecal  valve,  and  the  intussusceptum  stitched  to  the 
neck  of  the  intussuscipiens  by  two  fine  catgut  sutures.  Continuity  of  the  intestinal  canal 
restored  by  incising  the  ileum  above  the  obstruction  and  the  ascending  colon  below  the 
free  extremity  of  the  intussusceptum,  and  uniting  the  wounds  by  a  double  row  of  sutures. 
The  invagination  caused  no  serious  disturbance,  and  the  animal  remained  in  good  health, 
being  in  excellent  condition  at  the  time  of  killing,  one  hundred  and  sixty-two  days  after 
operation.  A  number  of  adhesions  between  the  folds  of  the  intestines  near  the  site  of 
operation.  At  point  of  junction  of  the  two  intestines  the  peritoneal  surface  presented  a 
glistening  and  continuous  surface.  New  opening  an  inch  and  a  half  in  length,  oval  in 
outline,  and  located  five  inches  above  the  ileocecal  region.  Two  inches  below  the  open- 
ing the  invagination  remained  in  the  shape  of  a  circular  thickening  of  the  bowel  with  a 
narrowing  of  its  lumen  to  more  than  one-half  of  its  normal  size.  A  close  inspection  of 
the  specimen  showed  that  no  gangrene  had  occurred,  but  that  the  intussusceptum  had 
undergone  atrophy.  A  stream  of  water  passing  along  the  ileum  in  a  downward  direction 
escaped  through  the  invaginated  portion  and  through  the  new  opening,  the  stream  from 
the  latter  being  at  least  three  times  larger  than  the  one  through  the  intussusceptum. 
Excluded  portion  of  ileum  and  colon  empty  and  very  much  atrophied  and  contracted. 
Below  the  new  opening  the  colon  and  rectum  contained  normal  feces  in  considerable 
quantity. 

ExPER  IMENT  80. — Young  cat.  Ileocecal  invagination  ;  length  of  intussusceptum  four 
inches,  and  in  order  to  prevent  spontaneous  disinvagination  the  bowel  was  fixed  in  its 
position  by  two  fine  catgut  sutures.  Ileocolostomy  below  the  lower  end  of  the  intussus- 
ceptum by  lateral  apposition  and  suturing.  Animal  died  on  the  fourth  day  after  opera- 
tion. Abdominal  wound  united.  Diffuse  peritonitis  from  perforation  at  site  of  suturing. 
Length  of  intussusceptum  reduced  from  four  inches  to  two  inches  and  a  half.  It  was 
found  impossible  to  effect  reducUon  by  traction  on  account  of  firm  adhesions  at  neck  of 
intussuscipiens.      No  gangi-ene. 

Experiment  81. — Adult,  large  dog.  Intestinal  obstruction  was  produced  by  making 
two  sharp  flexions  near  the  ileocecal  region  by  folding  the  bowel  on  its  side  and  fixing  it 
in  this  position  by  fine  catgut  sutures  ;  the  apices  of  the  flexions  were  sutured  together  so 
as  to  render  the  obstruction  more- complete.  Intestinal  anastomosis  was  established  by 
lateral  apposition  and  suturing.  Physical  condition  of  dog  remained  good  throughout ; 
appetite  and  evacuations  normal.  Killed  thirty-one  days  after  operation.  No  peritonitis  ; 
a  number  of  omental  adhesions  at  point  of  operation.  Flexions  quite  sharp,  rendering 
the  bowel  nearly,  if  not  completely,  impermeable  at  this  point.  Perfect  union  between 
bowels,  with  some  thickening  of  their  walls  by  inflammatory  exudation.  New  opening 
oval  in  shape,  an  inch  and  a  half  in  length,  a  few  of  the  deep  sutures  still  remaining 
attached  to  its  margins.     Excluded  portion  of  bowel  empty  and  somewhat  atrophic. 

Experiment  82.— Dog,  weight  thirteen  pounds.  Obstruction  of  the  bowels  made  by 
an  acute  flexion  four  inches  above  the  ileocecal  region,  retained  by  four  catgut  sutures. 
Intestmal  anastomosis  by  an  opening  an  inch  and  a  half  in  length,  which  brings  into 
communication  the  ileum  above  the  obstruction  and  the  descending  colon.  The  animal 
showed  no  untoward  symptoms,  and  was  killed  forty-one  days  after  operation.  A  num- 
ber of  intestinal  folds  agglutinated  by  adhesions  ;  no  evidences  of  diffuse  peritonitis. 
Where  the  flexion  had  been  made,  the  loop  of  intestine  is  connected  by  a  broad  band  of 


ILEOCOLOSTOMV    BY    PERFORATED    APPROXIMATION    DISCS.        837 

adhesion,  which  gives  to  the  bowel  a  horseshoe-shaped  appearance.  Intestine  below  the 
seat  of  flexion  contained  a  small  amount  of  hardened  feces.  Colon  and  cecum  above  the 
new  opening  nearly  empty  and  greatly  contracted.  Line  of  suturing  somewhat  thickened. 
New  opening  oval  in  outline  and  about  an  inch  in  length,  surrounded  by  a  corrugated 
elevation  of  mucous  membrane.  A  stream  of  water  passed  through  the  bowel  from 
above  downward  readily  escaped  through  the  new  opening,  while  only  a  small  stream 
could  be  forced  through  the  flexion. 

Experiment  83. — Dog,  weight  twenty-seven  pounds.  A  volvulus  was  made  six 
inches  above  the  ileocecal  region  by  rotating  an  empty  loop  of  the  intestine  once  around  its 
axis  and  fixing  it  in  this  position  by  three  catgut  sutures.  Intestinal  anastomosis  between 
the  ileum  above  the  volvulus  and  the  descending  colon  by  lateral  apposition  and  sutur- 
ing. For  four  days  after  the  operation  the  evacuations  from  the  bowels  contained  blood  ; 
after  this  time  the  stools  were  normal.  Dog  in  excellent  condition  when  killed,  thirty- 
one  days  after  operation.  No  signs  of  diffuse  peritonitis.  The  portion  of  bowel  that 
constituted  the  volvulus  adherent,  contracted,  and  empty.  Water  could  be  readily  forced 
through  this  part  of  the  bowel.  Cecum  and  colon  above  new  opening  empty  and  con- 
tracted. Size  of  new  opening  larger  than  the  lumen  of  the  ileum,  its  margins  surrounded 
by  a  prominent  ridge  of  mucous  membrane  to  which  a  few  of  the  deep  sutures  still  re- 
mained attached.  In  this  experiment  nearly  the  entire  colon  was  excluded,  consequently 
the  fecal  discharges  were  quite  frequent  and  fluid  or  semifluid  in  consistence. 

Experiment  84. — Dog,  weight  seventeen  pounds.  Two  inches  of  the  ileum  were 
invaginated  into  the  cecum,  lleocolostomy,  by  uniting  the  ileum  with  the  transverse 
colon  by  suturing.  The  animal  appeared  quite  ill  after  the  operation,  and  died  on  the 
fifth  day  after  having  manifested  well-marked  symptoms  of  peritonitis.  Abdominal 
wound  not  united.  Only  partial  union  between  the  intestines  at  point  of  junction.  Dif- 
fuse septic  peritonitis  from  perforation. 

In  at  least  two  experiments  that  are  not  here  reported  the  animals 
died  of  shock  a  few  hours  after  operation.  In  a  number  of  other 
experiments  the  operation  was  followed  by  more  or  less  shock,  but 
the  animals,  without  receiving  any  special  treatment,  rallied  after  from 
six  to  twelve  hours.  The  symptoms  referable  to  the  immediate 
effects  of  the  operation  were  due  to  the  length  of  time  required  in 
applying  a  double  row  of  sutures  in  uniting  the  visceral  wounds,  a 
step  in  the  operation  that  always  required  from  thirty  minutes  to  an 
hour.  These  experiments  only  corroborate  the  statement  previously 
made  that  the  excluded  portion  of  the  intestinal  canal,  including  the 
obstruction,  does  not  become  the  seat  of  fecal  accumulation,  but 
undergoes  atrophy  after  free  intestinal  anastomosis  has  been  estab- 
lished between  the  intestine  above  and  below  the  seat  of  obstruc- 
tion. Experiments  68  and  69  furnish  most  striking  proof  that  the 
danger  of  gangrene  in  ca.ses  of  invagination  is  greatly  diminished  by 
establishing  an  early  intestinal  anastomosis,  as  when  tiiis  is  done  the 
\'iolcnt  peristalsis  is  promptly  arrested  by  furnishing  a  new  outlet  to 
the  intestinal  contents  ;  at  the  .same  time,  the  .serious  con.sequences 
resulting  from  pressure  and  distention  above  the  obstruction  are  like- 
wi.se  promptly  averted.  In  ca.ses  of  intestinal  anastomosis  where 
nearly  the  entire  colon  has  been  excluded,  the  fluid  contents  of  the 
small  intestine  reach  the  rectum  at  once,  and  cause  frecjucnt  fluid 
fecal  di.scharges,  an  occurrence  that  does  not  appear  to  im])air  the 
general  health  of  the  animal.  The  new  ojjcning  should  be  made  of 
adequate  .size,  so  that  its  lumen  will  at  lea.st  corresj)on(l  to  the  lumen 
of  the  bowel  above  the  obstruction. 

Ile<)a)lostomy  by  Perforated  Approximation  Discs. 

Exil-.klMI.NI  85.-  iJog,  weight  twenty  p.niiid^.  The  il.imi  \v;is  K-niplctfiy  divided 
three  inches  above  the  ilctKccal  region,  jjoth  ends  dosed  by  iiivngiiiaiioii  and  three  stitches 


St,8  enterorrhaphy. 

of  the  continued  suture.  A  communication  was  established  between  the  proximal  ex- 
tremity and  the  colon  by  making  an  incision  into  the  ileum  on  convex  side  near  the  closed 
end,  and  introducing  through  this  opening  a  perforated  decalcified  bone-plate.  A  simi- 
lar opening  was  made  into  the  ascending  colon  opposite  its  mesenteric  attachment,  through 
which  a  perforated  plate  of  wood  was  introduced.  To  each  plate  were  tied  four  catgut 
sutures.  The  lateral  sutures  were  passed  through  the  margins  of  the  wound.  After  the 
plates  and  sutures  were  in  place,  the  wounds  were  brought  in  contact  and  the  four  sutures 
tied,  which  coaptated  the  serous  surfaces  of  both  bowels  over  an  area  corresponding  to  the 
size  of  the  plates.  The  animal  remained  apparently  well  for  two  days,  when  symptoms 
of  peritonitis  set  in  and  death  occurred  five  days  after  operation.  Diffuse  peritonitis. 
Union  at  point  of  operation  incomplete,  which  resulted  in  a  perforation.  Discs  had  dis- 
appeared. As  the  catgut  sutures  were  quite  fine,  it  is  more  than  probable  that  partial 
separation  of  the  plates  occurred  before  adhesions  had  taken  place  between  the  serous 
surfaces  of  the  coaptated  bowels,  which  resulted  in  perforation  and  death  from  diffuse 
septic  peritonitis. 

Experiment  86. — Dog,  weight  fifteen  pounds.  Invagination  of  colon  into  colon 
to  the  extent  of  two  inches.  Intestinal  anastomosis  by  making  an  ileocolostomy  by  lateral 
apposition  of  the  ileum  to  colon  below  invagination,  using  perforated  hard-rubber  plates, 
which  were  tied  together  by  four  catgut  sutures,  the  lateral  sutures  being  passed  through 
the  margins  of  the  wound.  After  tying  the  sutures  it  was  found  that  at  one  point  the 
margins  of  the  wound  showed  a  tendency  to  evert ;  consequently  a  fine  catgut  suture  was 
passed  through  the  peritoneum  only  and  tied.  The  animal  did  not  appear  bright  the  day 
after  the  operation,  but  subsequently  showed  no  signs  of  suffering.  Killed  twenty-four 
days  after  operation.  Abdominal  wound  fimily  united.  Omentum  adherent  to  wound 
and  ^t  point  of  operation.  The  invagination  was  partially  reduced.  The  bowel  at  this 
point  was  curved  in  the  shape  of  a  horseshoe,  but  permeable  to  a  stream  of  water.  Ex- 
cluded portion  of  colon  tortuous  and  atrophic.  Cecum  contained  a  small  quantity  of 
fluid  feces.  Plates  could  not  be  found.  New  opening  sufficiently  large  for  free  passage 
of  intestinal  contents. 

Experiment  87. — Dog,  weight  fifteen  pounds.  Ileum  divided  transversely  fifteen 
inches  above  the  ileocecal  region  ;  both  ends  closed  in  the  usual  manner.  Ileum  and 
colon  approximated  by  decalcified  perforated  bone-plates,  which  were  tied  together  by 
four  catgut  sutures,  the  lateral  ones  transfixing  the  margins  of  the  wound.  On  the  second 
day  the  evacuation  from  the  bowels  contained  traces  of  blood.  Animal  killed  eighteen 
days  after  operation.  Abdominal  wound  completely  healed.  Omentum  adherent  to 
wound.  Numerous  adhesions  between  the  intestinal  folds.  Proximal  blind  end  of  ileum 
had  been  changed  into  a  pouch-like  form  and  contained  a  mass  of  hair  and  fragments  of 
bone.  One  very  sharp  spiculum  of  bone  had  nearly  perforated  the  intestine.  New  open- 
ing corresponds  in  size  to  the  lumen  of  the  ileum. 

The  Operations  of  lateral  apposition  of  ileum  to  colon  by  per- 
forated approximation  discs  have  shown  that  it  is  unsafe  to  rely 
upon  catgut  as  a  suturing  material,  as  when  fine  catgut  is  used 
coaptation  is  not  maintained  for  a  sufficient  length  of  time  for  ad- 
hesions to  take  place,  and  coarse  catgut,  when  tied,  interferes  with 
accurate  approximation,  as  the  knots,  after  tying,  mechanically  sep- 
arate the  serous  surfaces.  It  is  advisable  to  use  removable  plates  and 
to  tie  with  silk.  The  results  of  ileocolostomy  made  by  approxi- 
mation discs  have  not  been  so  favorable  as  after  jejuno-ileostomy  or 
ileo-ileostomy,  and  in  repeating  the  operation  on  man  it  would  be 
indicated,  after  bringing  the  intestines  in  apposition  by  tying  the  four 
sutures,  to  apply  a  number  of  superficial  sutures  for  the  purpose  of 
still  further  guarding  against  the  escape  of  gas  or  fluid  contents  into 
the  peritoneal  cavity.  The  plates,  when  properly  fixed  in  their 
places  and  tied  together  with  sufficient  firmness,  not  only  coaptate 
an  extensive  area  of  serous  surfaces,  but  also,  at  the  same  time, 
secure  perfect  rest  for  the  parts  that  it  is  intended  to  unite  until  firm 
adhesions  have  formed. 

Clinical  experience  since  these  experiments  were  performed  has 


ILEORECTOSTOMY. 


839 


shown  that  intestinal  anastomosis  by  lateral  apposition  can  be  made 
by  suturing  quickly  and  safely,  preference  being  given  to  the  plates 
or  Murphy's  button  only  in  cases  in  which  the  intestinal  wall  is  in 

such  a   condition  that  safe  suturing  would  be  precluded that  is, 

when  it  is  extremel}'  thin,  softened  by  inflammation,  or  damaged  by 
contusion.  In  lateral  implantation  the  rubber  ring  can  safely  be 
dispensed  with,  and  invagination  may  be  effected  by  making  traction 
on  the  two  invagination  sutures,  completing  the  fixation  \v  a  row 
of  Lembert  stitches  closel}-  placed.  In  making  an  ileocolostomy  it 
is  well  to  unite  the  mesentery  of  the  implanted  part  of  the  ileum 
with  the  mesentery  of  the  colon  by  a  separate  stitch  as  an  additional 
means  of  fixation.  Maunsell  implants  the  ileum  into  the  colon  in 
the  same  manner  as  in  his  method  of  performing  circular  enter- 
orrhaphy.  As  the  method  appears  easy  and  of  practical  value,  his 
directions  are  here  quoted  : 

"Invaginate  the  cut  end  of  the  ileum  attached  to  the  cecum  and 
sew  it  up  with  a  continuous  suture. 

"  Make  a  slit  on  the  convex  surface  of  the  colon  sufficiently  long 
to  just  receive,  with  very  slight  constriction,  the  cut  end  of  the  ileum  ; 
secure  with  two  temporary  sutures,  leaving  the  ends  long. 

"  Make  a  slit  in  the  colon  an  inch  higher  up  or  an  inch  lower 
down  in  the  cecum,  whichever  is  most  convenient  for  the  invagi- 
nation. 

"  Pass  a  dressing  forceps  through  the  slit,  and  seize  the  two 
ends  of  the  temporary  sutures. 

"Drag  the  invaginated  cut  end  of  the  ileum  and  its  correspond- 
ing opening  in  the  colon  out  through  the  slit. 

"Suture  careful!}'  all  round,  and  pull  back  to  its  normal  po.sition. 

"Sew  up  the  longitudinal  slit  with  a  continuous  suture." 

Ileorectostomy. — In  cases  of  intestinal  obstruction  due  to  in- 
operable conditions  low  down  in  the  colon  it  becomes  necessary  to 
e.stablish  an  intestinal  anastomosis  between  the  ileum  and  the  rectum, 
in  order  to  avert  the  necessity  of  making  an  artificial  anus — in  other 
words,  to  perform  an  ileorectostomy.  The  operation  can  be  made 
in  the  .same  way  as  establishing  a  communication  between  the  ileum 
and  the  colon  by  lateral  implantation,  by  lateral  apposition  and 
double  suturing,  or  by  lateral  apposition  by  the  Murphy  button 
or  by  perforated  decalcified  bone-plates.  The  operation  is,  however, 
more  difficult,  because  the  rectum  is  not  so  accessible  as  the  colon, 
and  from  the  greater  vascularity  of  the  bowel  the  incision  is  more 
liable  to  give  rise  to  troublesome  hemorrhage.  While  the  slight 
hemorrhage  from  an  incision  into  the  small  intestine  and  tiie  colon 
is  usually  |)romptly  arrested  by  suturing  or  comjiression  by  the 
approximation  discs,  the  bleeding  from  the  wound  of  the  upper 
portion  of  the  rectum  not  infrequently  requires  the  application  of 
one  or  more  catgut  ligatures  before  it  is  safe  to  unite  the  wounds. 
During  the  operation  traction  must  be  made  upon  the  rectum  in  an 
u[>war(I  direction  so  as  tc;  lift  the   upfjcr  poition  of  the  bowel  out 


840  ENTERORRHAPHY, 

of  the   pelvis.      In   both   of  the   experiments    described   below  the 
wounds  were  united  by  Czerny-Lembert  sutures  : 

Experiment  88. — Dog,  weight  ninety  pounds.  Invagination  of  colon  into  colon 
for  two  inches,  and  suturing  of  intussusceptum  to  neck  of  intussuscipiens  by  four  fine  silk 
sutures  to  prevent  spontaneous  disinvagination.  Ileum  incised  in  a  parallel  direction  for 
an  inch  and  a  half  on  convex  side,  and  this  wound  united  with  a  similar  incision  in  the 
rectum  on  its  anterior  surface  by  a  double  row  of  sutures.  For  the  purpose  of  immobiliz- 
ing the  sutured  intestines  an  additional  fine  catgut  suture  was  applied  above  and  below 
the  place  of  suturing,  embracing  only  the  peritoneal  and  muscular  coats  of  the  intestines. 
On  the  third,  fourth,  and  fifth  days  the  fecal  discharges  contained  blood  aiid  mucus.  On 
the  sixth  day  the  abdominal  wound  partially  opened,  and  a  considerable  quantity  of  sero- 
purulent  fluid  escaped.  Death  seven  days  after  operation.  Abdominal  wound  not 
united.  Diffuse  purulent  peritonitis.  Numerous  intestinal  adhesions.  Invagination 
retained  ;  adhesions  between  the  intussusceptum  and  intussuscipiens ;  no  gangrene  ;  per- 
foration at  point  of  operation. 

Experiment  89. — Cat,  weight  seven  pounds.  Ileorectostomy  by  lateral  implanta- 
tion. The  ileum  was  cut  across  transversely  an  inch  above  the  ileocecal  valve,  and  the 
distal  end  closed  by  invagination  and  three  stitches  of  the  continued  suture.  The  prox- 
imal end  was  transplanted  into  a  longitudinal  incision  on  the  anterior  surface  of  the  upper 
portion  of  the  rectum  by  Czerny-Lembert  suture.  With  the  exception  of  an  occasional 
slight  rise  in  temperature,  no  serious  disturbances  were  observed  during  the  progress  of 
the  case.  The  evacuation  of  the  small  intestine  directly  into  the  rectum  appeared  to 
increase  the  peristaltic  action  of  the  rectum,  as  the  fecal  discharges  were  fluid  and  fre- 
quent. Animal  killed  twenty  days  after  operation.  Abdominal  wound  completely 
united.  No  peritonitis.  A  few  folds  of  the  small  intestine  and  the  omentum  adherent 
to  the  wound.  Insertion  of  ileum  into  rectum  in  an  oblique  direction  ;  union  at  point 
of  junction  complete  throughout ;  intestinal  coats  at  this  point  somewhat  thickened.  Peri- 
toneal surface  smooth  and  continuous  from  one  bowel  to  the  other.  New  ileorectal 
opening  corresponded  in  size  to  the  lumen  of  the  ileum  ;  margins  of  this  opening  con- 
sisted of  a  ridge  of  mucous  membrane  to  which  a  row  of  the  deep  .sutures  remained 
attached.  Excluded  portion  of  large  intestine  empty  and  contracted.  Rectum  contained 
a  small  quantity  of  fluid  feces. 

Colorectostomy. — Among  the  many  possibilities  in  the  opera- 
tive treatment  of  intestinal  obstruction,  a  condition  might  be  met 
with  where  the  seat  of  obstruction  is  located  low  down  in  the  colon, 
perhaps  in  the  sigmoid  flexure,  and  where  it  might  be  impossible 
or  impracticable  to  remove  the  cause  of  obstruction,  it  becoming 
necessary,  in  such  a  case,  to  restore  the  continuity  of  the  intestinal 
canal  by  establishing  a  communication  between  the  permeable  por- 
tion of  the  colon  and  the  rectum.  Such  an  anastomosis  can  be 
made,  as  in  ileocolostomy,  by  lateral  implantation,  lateral  apposi- 
tion by  the  Murphy  button,  perforated  approximation  plates,  or  by 
double  suturing.  For  want  of  time  one  experiment  only  was  made, 
and  although  the  animal  died  of  the  immediate  effects  of  the 
operation,  the  local  conditions  at  the  site  of  operation  found  after 
death  show  that  colorectostomy  in  selected  cases  is  not  only  a  jus- 
tifiable and  feasible  operation,  but,  whenever  it  can  be  done,  is  also 
always  preferable  to  the  formation  of  an  artificial  anus.  As  the 
operation  by  lateral  apposition  requires  much  less  time  than  lateral 
implantation,  it  should  be  preferred  to  the  latter  procedure,  and 
should  be  done  in  this  locality  in  preference  with  the  Murphy  but- 
ton and  a  few  superficial  sutures. 

This  operation  has  recently  been  described  as  a  new  one,  but  I 
conceived  the  idea  twelve  years  ago  and  carried  it  into  effect  in  the 
experiment  given  below : 


INVAGINATION    SUTURE. 


841 


Experiment  90.— Medium-sized  cat.  Incision  through  the  linea  alba  ;  colon  cut 
transversely  in  the  middle  third  and  the  distal  portion,  and  the  rectum  cleared  of  its 
contents  by  injecting  a  stream  of  warm  water  from  the  cut  end  downward,  a  procedure 
that  could  be  well  accomplished  only  after  forcible  dilatation  of  the  sphincter  ani  muscles. 
The  distal  end  was  closed  in  the  usual  manner.  The  rectum  was  drawn  ujnvaid,  and  aii 
incision  made  into  its  anterior  wall  large  enough  to  correspond  with  the  lumen  of  the 
colon.  Into  this  opening  the  iiroxiinal  end  of  the  colon  was  implanted  by  two  rows  of 
sutures.  During  the  latter  part  of  the  operation,  which  lasted  over  an  hour,  the  animal 
was  seized  by  convulsions  that  continued  for  several  hours,  and  finally  subsided  under  the 
administration  of  whisky  given  hyjiodermically.  The  .symptoms  of  shock,  however,  con- 
tinued, and  death  occurred  thirty-six  hours  after  operation.  Numerous  oiiiental  adhesions  ; 
closed  end  of  bowel  congested  ;  peritoneal  surfaces  adherent  ;  colon  and  rectum  at  point 
of  implantation  adherent. 

In  cases  where  the  obstruction  is  located  some  distance  from  the 
rectum  and  where  it  would  be  impossible  to  approximate  the  per- 
meable portion  of  the  colon  with  the  rectum,  the  entire  colon  must 
be  excluded  and  the  continuity  of  the  intestinal  canal  restored  by 
ileocolostomy  or  ileorectostomy.  In  all  cases  of  intestinal  anasto- 
mosis where  the  communication  is  made  in  the  lower  portion  of  the 
colon  or  the  rectum,  the  sphincters  of  the  anus  should  be  rendered 
temporarily  incompetent  by  stretching,  for  the  purpose  of  guarding 
against  oxerdistention  of  this  part  of  the  bowel  during  the  time 
required  for  the  healing  process  between  the  united  intestines. 

Invagination  Suture. — Another  method  of  effecting  a  speedy 
and  comparatively  safe  end-to-end  junction  is  by  my  modification 
of  Jobert's  invagination  suture  : 

According  to  Madelung,  the  ingenious  method  of  circular  sutur- 
ing devised  by  Jobert  was  practised  in  only  four  cases,  and  two  of 
the  patients  are  known  to  have  recovered.  A  nimiber  of  )'ears  ago 
I  was  forced  to  resort  to  resection  of  a  part  of  the  small  intestine  in 
a  very  complicated  case  of  ovariotomy,  and  resorted  to  this  method. 
Although  the  patient  died  forty-eight  hours  after  the  operation  from 
causes  out.side  of  this  complication,  the  bowel  was  found  permeable 
and  quite  firmly  united,  and,  had  the  patient  lived,  there  is  but  little 
doubt  the  result  of  the  resection  and  suturing  would  have  been  sat- 
isfactory. In  Jobert's  method  the  invagination  sutures  must  be 
looked  upon  as  a  source  of  danger,  as  they  were  made  to  traverse 
the  entire  thickness  of  the  wall  of  the  bowel,  and  the  material  u.sed 
was  silk.  It  has  been  claimed  that  in  this  method  the  invaginated 
portion  of  the  bowel  becomes  gangrenous,  as  in  cases  of  invagina- 
tion from  fjathologic  causes.  This  claim  has  arisen  from  a  theoretic, 
and  not  from  an  experimental,  standpoint.  In  cases  of  invagination 
the  intussusceptum  carries  with  it  the  mesenteric  ves.sels  intact  in  tlie 
form  of  an  arch,  which,  by  constriction  at  the  neck  of  the  intussus- 
ci[)iens,  is  prone  to  become  strangulated,  an  event  that  is  followetl  by 
cfleina  and  inflammatory  swelling  of  the  invaginated  jjortion,  which 
rapidly  tends  to  complete  venous  .stasis  and  gangrene.  In  circular 
suturing  by  Jobert's  method  the  intussusceptum  has  no  va.scular 
connection  with  the  intussuscijjiens.  The  vascular  arch  is  inter- 
rupted, and  consequently  the  danger  arising  from  venous  oj)struction 
is   almost   completely   obviated.      My  experiments   will    show   that 


842 


ENTERORRHAPHY. 


gangrene  of  the  invaginated  portion,  as  a  rule,  does  not  occur,  and 
my  modification  of  Jobert's  method  consists  essentially  in  the  use 
of  a  thin  elastic  rubber  ring  for  lining  the  intussusceptum  to  prevent 
ectropion  of  the  mucous  membrane,  to  protect  the  mucous  mem- 
brane of  the  bowel  against  injurious  pressure  from  the  suture,  to 
keep  the  lumen  of  the  bowel  patent  during  the  inflammatory  stage, 
and  to  assist  in  maintaining  coaptation  of  the  serous  surfaces  ;  and, 
further,  the  substitution  of  catgut  for  silk  as  invagination  sutures. 

The  operation  is  performed  as  follows  :  The  upper  end  of  the 
bowel,  which  is  to  become  the  intussusceptum,  is  lined  with  a  soft, 
pliable  rubber  ring  made  of  a  rubber  band,  transformed  into  a  ring 
by  fastening  the  ends  together  with  two  catgut  sutures.  This  ring 
must  be  the  length  of  the  intussusceptum, — from  one-third  to  half 
of  an  inch, — and  its  lower  margin  is  stitched  by  a  continuous  catgut 
suture  to  the  lower  end  of  the  bowel,  effectually  preventing  the 
bulging  of  the  mucous  membrane,  a  condition  that  is  always  diffi- 


cult to  overcome  in  circular  suturine. 


After  the  ring  is  fastened  in 


Fig-  5^7- — Senn's  modification  of  Jobert's  invagination  suture  (after  Baracz)  :  a.  Upper 
end  lined  with  soft-rubber  ring  ;  b,  invagination  sutures  in  place  ;  c,  lower  end. 

its  place,  the  end  of  the  bowel  presents  a  tapering  appearance  that 
materially  facilitates  the  process  of  invagination.  Two  well-pre- 
pared fine  juniper  catgut  sutures  are  threaded,  each  with  two  needles. 
The  needles  are  passed  from  -within  outward,  transfixing  the  upper 
portion  of  the  rubber  ring  and  the  entire  thickness  of  the  wall  of 
the  bowel,  and  always  equidistant  from  each  other.  The  first  suture 
is  passed  in  such  a  manner  that  each  needle  is  brought  out  a  short 
distance  from  the  mesenteric  attachment,  and  the  second  suture  on 
the  opposite  convex  side  of  the  bowel.  During  this  time  an  assist- 
ant keeps  the  opposite  end  of  the  bowel  compressed,  to  prevent 
contraction  and  bulging  of  the  mucous  membrane.  The  needles 
are  passed  next  through  the  peritoneal,  muscular,  and  connective- 
tissue  coats  at  corresponding  points,  about  one-third  of  an  inch 
from  the  margins  of  the  opposite  end  of  the  bowel,  and  when  all  the 
needles  have  been  passed,  an  assistant  makes  equal  traction  on  the 
four  strings,  and  the  operator  assists  the  invagination  by  turning  in 


INVAGINATION    SUTURE.  843 

the  margins  of  the  lower  end  evenly  with  a  director,  and  by  gently 
pushing  the  rubber  ring  completely  into  the  intussuscipiens.  The 
invagination  accurately  made,  the  two  catgut  sutures  are  tied  with 
only  sufficient  firmness  to  prevent  disinvagination  should  violent 
peristalsis  follow  the  operation.  This  is  their  sole  function.  The 
invagination  itself  effects  accurate,  almost  hermetic,  sealing  of  the 
visceral  wound.  The  intestinal  contents  pass  freeK'  tiirough  the 
lumen  of  the  rubber  ring  from  above  downward,  and  escape  from 
below  is  impossible,  as  the  free  end  of  the  intussuscipiens  secures 
accurate  valvular  closure.  After  a  few  days  the  rubber  ring  becomes 
detached,  and,  by  giving  way  of  the  catgut  sutures,  is  again  trans- 
formed into  a  flat  band  that  readily  passes  off  with  the  discharges 
through  the  bowels.  The  invagination  sutures  of  catgut  are  grad- 
ually removed  by  substitution  on  the  part  of  the  tissues,  hence  the 
punctures  in  the  bowel  remain  clo.sed  either  by  the  catgut  or  by  the 
products  of  local  tissue  proliferation  ;  thus  extravasation  is  prevented. 
In  the  first  experiments  three  invagination  sutures  were  used,  but  it 
was  found,  by  experience,  tiiat  two  are  just  as  efficient  in  making 
and  retaining  the  invagination.  No  superficial  or  peritoneal  sutures 
were  used  in  any  of  the  cases,  sole  reliance  being  placed  upon  the 
invagination  to  maintain  approximation  and  coaptation.  The  mes- 
enteric attachment,  both  of  the  intussusceptum  and  intussuscipiens, 
was  separated  only  a  few  lines,  to  enable  invagination  without  too 
much  narrowing  of  the  lumen  of  the  intussuscipiens. 

Experiment  42. — Uog,  weight  fifteen  pounds.  Three  invagination  sutures  were  used. 
The  ileum  was  cut  comi)letely  across,  at  a  point  about  three  feet  above  the  ileocecal  region. 
Depth  of  invagination  one  inch.  For  two  days  after  operation  a  slight  rise  in  temperature ; 
no  symptoms  of  obstruction  during  the  whole  time.  Animal  in  gcwd  condition  when 
killed,  two  weeks  after  operation.  Omentum  adherent  at  point  of  operation  as  well  as 
on  adjacent  kx)])  of  intestine.  Union  between  intussusceptum  and  intussuscipiens  firm  ; 
no  signs  of  gangrene.  Narrowest  portion  of  lumen  of  bowel  was  large  enough  to  i)ass  the 
little  finger  to  second  joint.  An  enterolith  composed  of  fragments  of  wood,  bone,  etc., 
in  the  center  of  which  the  straight  rubber  band,  which  had  been  the  rubber  ring,  was 
found  just  above  the  seat  of  operation.  No  distention  of  the  bowel  above  this  p(jinl. 
IV)wel  considerably  flexed  at  seat  of  invagination,  this  condition  being  evidently  brought 
about  by  inflammatory  adhesions. 

Kxt'KklMENT43. — Dog,  weight  twenty  pounds.  Section  of  bowel  and  invagination 
with  rubber  ring  the  .same  as  in  the  foregoing  experiment.  In  subseiiueiit  history  no 
mention  is  made  of  any  .symptom  of  obstruction,  but  for  the  last  few  weeks  it  was  noticed 
that  the  dog  began  to  emaciate.  He  died  siiddiiily  eighty-one  days  after  the  o])eralion. 
Diarrhea  was  a  prominent  symptom  toward  the  last.  No  a<lhesions  and  no  peritonitis. 
An  enormous  enterolith,  composed  of  all  kinds  of  crude  material  and  again  holding  in 
its  center  the  rubber  band,  was  found  just  above  the  invagination.  Bowel  at  this  ])lace 
considerably  dilated.  Intussusceptum  firmly  adherent  ;  a  false  passage  admitting  llie  lii) 
of  (he  little  finger  had  been  made  on  one  side,  between  it  and  the  intussuscipiens.  1  )ealli 
in  this  case  was  evidently  jiroduced  by  the  enterolith.  In  this,  as  in  the  last,  case,  (he 
invagination  was  made  at  least  an  inch  in  length,  and  the  collection  of  (he  crude,  ituligest 
ibie  material,  which  the  dog  must  have  eaten  in  large  quantities,  around  (he  de(aclied 
rubber  ring  gave  rise  to  the  enteroli(h.  The  wall  of  the  bowel  surrounding  (he  foreign 
bmly  was  not  only  dilated,  but  also  greatly  thickened.  I(  is  a  well-known  fnc(  that  even 
a  moderate  degree  of  stenosis  of  the  bowel  in  dogs  is  liable  to  give  rise  to  ihe  formation  of 
an  enleroli(h,  as  the  crude  material  that  (he.se  animals  swallow  becomes  arreste<l,  and,  by 
constant  accretions  of  the  same  kind  of  material,  the  enterolith  forms  and  KintinucM  to 
increase  in  size  until  its  presence  causes  catarrhal  inflamma(i<jn  and  finally  intestinal 
obstruction. 

It  is  quite  possible  that  the  lower  end  of  the  intussusceptum  in  (he  last  case  became 


844  ENTERORRHAPHY. 

impermeable  during  the  inflammatory  stage,  and  that  the  false  passage  was  formed  on 
this  account  by  perforation  on  one  side  of  the  intussusceptum,  an  accident  that  was 
plainly  traceable  to  too  deep  invagination. 

Experiment  44. — Dog,  weight  forty  pounds.  This  experiment  is  interesting  only 
from  the  fact  that  it  shows  that  it  is  possible  to  make  a  mistake  in  the  direction  of  the 
invagination,  even  after  the  operation  has  determined  with  accuracy  which  is  the  ascend- 
ing and  descending  end  of  the  bowel,  and  to  show  the  disastrous  consequences  that  must 
necessarily  follow  such  a  technical  mistake.  The  invagination  was  made  in  the  usual 
manner,  with  rubber  ring  and  three  catgut  sutures.  The  animal  appeared  to  be  quite  ill 
the  day  following  the  operation,  and  on  the  next  day  the  thermometer  showed  a  rise  in 
temperature  to  104.2°  F.  On  the  third  day  the  dog  died,  with  well-marked  symptoms 
of  perforative  peritonitis.  Recent  peritonitis  with  some  agglutinations  of  intestines. 
Considerable  quantity  of  serosanguinolent  fluid  in  the  peritoneal  cavity.  To  the  utter 
astonishment  of  all,  it  was  found  that  an  ascending  invagination  had  been  made.  Circu- 
lar gangrene  of  intussusceptum  and  complete  separation  of  ends  were  found.  The  rubber 
ring  remained  in  situ  still  attached  to  the  intussuscipiens  by  the  catgut  sutures,  which 
had  become  somewhat  softened.  The  invagination  had  decreased  considerably  by  the 
traction  caused  by  the  peristalsis  and  by  the  pressure  of  the  intestinal  contents  from  above 
the  obstruction,  and  the  extensive  gangrene  of  the  bowel  was  undoubtedly  determined  to 
a  great  extent  by  these  causes. 

Experiment  45. — As  an  illustration  of  another  source  of  danger  due  to  faulty  technic, 
the  next  experiment  will  prove  of  practical  interest.  Medium-sized  dog.  Circular  en- 
terorrhaphy  was  done  with  the  rubber  ring  two  feet  above  the  ileocecal  valve.  In  making 
the  invagination  it  was  noticed  that  the  ring  was  too  large,  as  it  was  seen  that  it  caused 
too  much  pressure.  Thinking  that  the  parts  might  adapt  themselves  to  this  pressure,  the 
bowel  was  replaced  and  the  abdominal  wound  closed.  The  dog  died  thirty-six  hours 
after  the  operation.  Abdominal  wound  not  united  ;  omentum  and  intestines  adherent  to 
each  other  and  at  point  of  operation.  The  circumscribed  gangrene  of  the  intussuscip- 
iens was  evidently  entirely  due  to  pressure  on  part  of  the  rubber  ring.  The  intussuscip- 
iens was  much  swollen,  a  condition  that  materially  aggravated  the  pressure  caused  by  the 
rubber  ring.  With  the  following  experiment  two  new  departures  were  inaugurated — ■ 
viz.,  the  inserting  of  two  sutures  instead  of  three,  thus  still  further  shortening  the  time 
required  for  performing  the  operation  ;  and  the  using  of  Nothnagel's  test  in  determining 
the  direction  in  which  the  invagination  should  be  done.  In  all  the  remaining  experiments 
of  circular  enterorrhaphy  that  were  made  only  two  catgut  sutures  were  used.  Until  now 
it  was  always  necessary  to  find  one  of  the  extremities  of  the  small  intestine  for  the  pur- 
pose of  determining  which  was  the  afferent  and  which  the  efferent  end  of  the  tube,  so  as 
to  make  the  invagination  in  the  right  direction,  a  procedure  that  often  required  consider- 
able time  and  brought  additional  risk  by  increasing  the  shock  of  the  operation  and  the 
danger  of  traumatic  infection. 

Experiment  46. — Dog,  weight  thirty  pounds.  Circular  section  of  ileum  and  im- 
mediate enterorrhaphy  by  invagination  with  rubber  ring  and  two  catgut  sutures.  Intus- 
susceptum invaginated  not  more  than  a  quarter  of  an  inch.  A  few  days  after  the  oper- 
ation stools  mixed  with  blood  ;  no  other  unfavorable  symptoms.  Animal  killed  fourteen 
days  after  operation.  Wound  united  firmly.  A  number  of  omental  and  intestinal  adhe- 
sions. A  small  abscess  in  mesentery  at  point  of  operation.  No  obstruction  of  any  kind. 
On  opening  the  bowel  the  walls  at  site  of  operation  were  very  thick,  corresponding  to  the 
three  intestinal  coats,  which  had  become  considerably  attenuated.  The  inner  surface 
shows  the  point  of  junction  of  the  intussusceptum  with  the  intussuscipiens  in  the  shape 
of  a  circular  ring  of  mucous  membrane.  The  most  contracted  portion  is  large  enough  to 
admit  the  little  finger. 

Experiment  47. — Dog,  weight  fifteen  pounds.  Section  of  ileum  and  circular  en- 
terorrhaphy with  rubber  ring  and  two  catgut  sutures.  Depth  of  invagination,  one-third 
of  an  inch.  No  unfavorable  symptoms  after  operation.  Animal  killed  after  seven  days. 
Wound  completely  united.  Firm  union  of  visceral  wound  ;  no  gangrene  of  intussuscep- 
tum. Rubber  ring  retained  in  situ  by  catgut  sutures,  which  are  easily  torn.  Upper  end 
of  ring  matted  with  hair.  No  obstruction.  Lumen  of  bowel  somewhat  contracted  by  a 
circular  ridge  of  mucous  membrane,  which  indicates  the  junction  of  the  two  invaginated 
ends  of  the  bowel. 

Nothnagel's  Test. — In  making  an  end-to-end  junction  by  invagi- 
nation it  is  very  important  to  determine  which  is  the  proximal  and 
which  the  distal  end,  as  the  former  is  always  invaginated  into  the 
latter.     In  the  absence  of  other  indications    or  means   this   differ- 


NOTHNAGEL  S    TEST. 


845 


entiation  can  be  accomplished  with  some  degree  of  positiveness  by- 
resorting  to  Nothnagel's  test. 

In  experimenting  upon  animals  for  the  purpose  of  studying  the 
functions  of  the  intestinal  canal  in  health  and  disease  Nothna^-el 
made  the  discovery  that  when  the  salts  of  potash  are  brought  in 
contact  with  the  serous  surface  of  the  bowel,  circular  constriction 
takes  place,  and  when  the  peritoneal  surface  is  touched  with  a  crys- 
tal of  common  salt,  ascending  peristalsis  is  produced.  The  sodic 
chlorid  test  was  applied  in  sixteen  cases,  and  by  subsequent  anatomic 
examination  Nothnagel's  observ^ations  were  corroborated  in  fifteen 
cases.  In  the  remaining  case,  where  a  wrong  conclusion  was 
drawn,  the  error  might  have  been  due  to  a  faulty  observation,  or, 
perhaps,  the  observation  was  not  continued  for  a  sufficient  length  of 
time.  If,  in  the  human  subject,  these  observations  could  be  veri- 
fied, it  would  be  of  great  practical  importance  to  surgeons  in  oper- 
ations on  the  intestinal  canal  whenever  it  becomes  necessary  to 
determine  which  is  the  ascending  and  which  the  descending  part  of 
the  bowel. 

In  circular  enterorrhaphy,  as  in  cases  of  intestinal  wounds  of 
any  kind,  the  ideal  of  any  operation  should  be  to  bring  in  continu- 
ous uninterrupted  apposition  a  large  surface  of  serous  membrane, 
without,  at  the  same  time,  interfering  with  the  vascular  supply  of 
the  parts  that  it  is  intended  to  bring  together  for  permanent  union 
by  cicatrization.  If,  in  employing  the  Czerny-Lembert  sutures, 
more  than  a  few  lines  of  the  margins  of  the  bowel  are  inverted  and 
included  between  the  two  rows  of  sutures,  there  is  great  danger  of 
causing  primary  traumatic  stenosis  by  the  projecting  circular  ring 
in  the  lumen  of  the  bowel.  The  narrowing  of  the  lumen  of  the 
bowel  mu.st  be  as  great,  if  not  greater,  than  after  invagination. 
That  the  second  row  of  sutures  has  often  been  the  cause  of  gan- 
grene of  the  inverted  margin  of  the  bowel  would  not  be  difficult  to 
prove  by  many  posmiortem  records  and  specimens.  By  invaginating 
to  the  depth  of  a  quarter  or  third  of  an  inch,  accurate  coaptation  of 
the  corresponding  serous  surfaces  between  the  intussusceptum  and 
intu.ssuscipiens  is  .secured,  and  this  coaptation  is  made  more  secure 
and  effective  by  the  elastic  pressure  exerted  by  the  rubber  ring. 
This  method  of  Cf)aptation  furnishes  a  large  peritoneal  surface  for 
immediate  union  by  cicatrization.  With  perhaps  one  excejjtion,  all 
the  experiments  have  shown  that  when  catgut  is  u.scd  for  invagina- 
tion sutures  none  of  the  failures  was  attributable  to  their  presence. 
On  the  inner  side  of  the  bowel  the  rubber  ring  is  drawn  against  the 
puncture,  and  would  thus  furnish  a  mechanical  protection  against 
the  escape  of  fluids  of  the  invaginated  portions,  which  finally  appear 
only  as  a  prominent  ridge  of  mucous  membrane  on  the  inner  surface 
of  the  bowel,  the  remaining  coats  having  com[)letely  or  nearly  dis- 
ap[)eared  by  retrograde  metamorphosis  and  absorption.  In  the 
healing  of  all  wounds  one  important  condition  for  an  ideal  result  is 
rest.      The  rubber  ring  in  tlie  intu.ssusceptum  .secures  this  important 


846  ENTERORRHAPHY. 

condition  for  the  invaginated  portion,  as  the  elastic  pressure  must 
overcome  peristaltic  action  and  secure  for  this  segment  of  the 
bowel,  as  near  as  possible,  absolute  physiologic  rest.  The  danger  of 
stenosis  after  invagination  is  greatest  as  soon  as  inflammatory  swell- 
ing makes  its  appearance, — a  day  or  two  after  the  operation, — and 
the  rubber  ring  is  again  in  the  right  place  to  prevent  any  undue 
swelling  by  affording  a  gentle  support  for  the  invaginated  portion, 
which  can  not  fail  in  preventing  undue  venous  engorgement  and 
edema,  which  would  otherwise  follow  the  invagination.  It  serves 
both  the  purpose  of  a  splint  and  an  elastic  bandage.  After  union 
of  a  bowel  by  invagination  with  a  rubber  ring  peritoneal  sutures  are 
superfluous,  as  the  invagination  itself  most  effectually  prevents  any 
escape  of  intestinal  contents  by  the  valvular  action  of  the  invagin- 
ated portion  ;  at  the  same  time  the  serous  surfaces  are  kept  in  per- 
manent and  uninterrupted  contact  by  the  elastic  pressure  on  the  part 
of  the  rubber  ring. 

Although  the  experiments  have  demonstrated  the  safety  of  the 
catgut  invagination  sutures  in  operating  upon  dogs,  the  same  innoc- 
uity  might  not  attend  operations  after  intestinal  resections  for  obstruc- 
tion, as  in  such  cases  the  coats  of  the  bowel  are  almost  without 
exception  very  much  attenuated,  and  consequently  the  danger  of 
extravasation  along  the  needle  punctures  would  be  increased.  Very 
recent  trials  have  proved  that  invagination  after  circular  resection 
can  be  done  with  the  rubber  ring  with  facility  and  probably  greater 
safety  by  dispensing  with  the  invaginating  sutures  and  adopting  the 
following  plan  :  The  lower  end  of  the  intussusceptum  is  lined  with 
a  soft-rubber  ring  about  one-quarter  to  one-third  of  an  inch  in  width, 
and  with  a  lumen  of  sufficient  size  to  afford  free  transit  to  the  intes- 
tinal contents.  The  lower  margin  of  the  ring  is  stitched  to  the  end 
of  the  intussusceptum  by  a  continued  fine  catgut  suture.  The  ends 
of  the  bowel  are  now  brought  in  contact  and  fastened  together  with 
four  catgut  sutures  that  are  placed  equidistan*from  one  another. 
Invagination  is  now  made  by  gently  pushing  the  ends  of  the  bowel 
in  opposite  directions,  being  careful  to  push  the  ring  sufficiently 
deep  so  that  its  upper  margin  is  grasped  by  the  neck  of  the  intus- 
suscipiens.  A  few  superficial  sutures  are  applied  simply  for  the 
purpose  of  preventing  disinvagination  :  the  four  catgut  sutures  act 
as  invagination  sutures,  and  at  the  same  time  prevent  ectropion  of 
the  mucous  membrane  of  the  lower  end  of  the  bowel  during  and 
after  invagination.  With  proper  facilities  and  good  assistance  a  cir- 
cular enterorrhaphy  can  be  made  in  this  manner  in  ten  minutes 
without  using  invagination  sutures  ;  and  by  using  not  more  than  four 
retention  sutures,  the  blood  supply  to  the  inverted  portions  is  not 
impaired,  and  at  the  same  time  the  two  ends  of  the  bowel  have  been 
joined  together  by  a  large  surface  of  peritoneum,  which  is  held  in 
accurate  contact  for  rapid  union  by  granulation  and  cicatrization. 

The  advantages  that  are  derived  from  covering  a  sutured  intes- 
tinal wound  by  an  omental  flap  are  self-evident.      The  procedure  is 


FORMS    OF    OBSTRUCTION.  847 

simply  an  imitation  of  nature's  process  in  protecting  the  peritoneal 
cavity  against  perforation  and  in  hastening  the  liealing  of  the  vis- 
ceral wound.  An  adherent  omentum  secures  rest  for^'the  part  to 
which  it  has  become  attached.  As  the  omental  flap  becomes  firmly 
adherent  before  definitive  healing  of  the  visceral  wound  has  tak'en 
place,  it  furnishes  additional  protection,  and,  in  the  event  of  a  small 
perforation,  it  guards  against  perforative  peritonitis  by  mechanically 
preventing  the  entrance  of  pus  into  the  peritoneal  cavity.  Should 
pus  reach  the  omental  flap  after  it  has  become  firmly  adherent,  it  is 
not  very  probable  that  perforation  would  take  place  through  the  two 
layers  of  peritoneum  furnished  by  the  adherent  omental  flap,  and 
the  subsequent  healing  of  the  perforation  of  the  bowel  would  be 
most  likely  to  take  place.  Allusion  to  this  subject  has  already  been 
made  under  the  head  of  Omental  Graftino^. 


CHAPTER  XXIV. 


ANATOMICOPATHOLOGIC  FORMS  OF  INTESTINAL 
OBSTRUCTION. 

In  the  introductory  section  stress  was  placed  on  the  importance 
of  the  classification  of  intestinal  obstruction  into  acute  and  chronic; 
this  was  done  rather  from  a  practical  than  from  a  scientific  stand- 
point. But  an  exclusive  reliance  on  such  a  differentiation  at  the 
bedside  will  not  infrequently  lead  to  faulty  practice,  as  a  chronic 
obstruction  may  give  rise  to  slight  symptoms  until  suddenly  the  clini- 
cal picture  of  acute  obstruction  is  developed  ;  on  the  other  hand, 
in  acute  obstruction  under  expectant  treatment  the  stormy  s\-mp- 
toms  may  sub.side,  to  be  followed  by  manifestations  indicating  the 
existence  of  a  chronic  obstruction.  A  scientific  classification  of 
intestinal  obstruction  remains  a  desideratum  to  be  accomplished  by 
future  experimentation  and  pathologic  and  clinical  investigations.  A 
step  in  the  right  direction  was  initiated  by  von  Wahl,  who  aimed  to 
base  the  classification  on  the  pathologic  conditions  of  the  ob.structed 
portion  of  the  intestine  itself  Following  this  suggestion,  his 
as.sistant,  W.  von  Zoege-Manteuffel,  proposes  the  following  schema: 

I.  .STRANGULATION  OH.STRUCTION. 
Pathologic  Changes.  Ci.inicai.  .Svmi-toms. 

1.  IxKalizcfl     tym[)aiiite.s ;     distention     of      i.    (^/)  Asymmetries   on    the   abdomen. 

strangulated   loop.  (//)  Localized  resistance. 

2.  Lschemic   paralysis    of  the  strangulated     2.   Complete  rest  of  loop  lyinj.;  against  ah- 

h>op.  dominal  wall  ;  no  peristalsis. 

In  this  category  are  included  : 

1.  Volvulus,  twists. 

2.  Ohstniction  from  bands  and  diverticula. 

3.  Incarceration  in  preformed  spaces — internal  hernia. 

4.  Invagination. 


848  FORMS    OF    OBSTRUCTION. 

II.  OBTURATION  OBSTRUCTION. 

Pathologic  Condition.  Clinical  Symptoms. 

1.  Tympanites  caused  by  accumulation  of  Appreciable    asymmetry,    palpable     resist- 

intestinal  contents  above  obstruction.  ance  in  obstruction  of  the  large  intes- 

2.  {a)  No  considerable  disturbance  of  cir-  tine.      In  obstruction  of  small  intestine 

culation.  diffuse  tympanites. 

(d)    Hypertrophy    of     muscular    coat  (a)  Peristalsis  visible  or  palpable. 

above  obstruction  in  the  chronic  form  (d)  Peristalsis  strong. 

when  the  large  intestine  is  affected. 

To  this  group  belong : 

1.  Strictures. 

2.  Twist  around  the  axis  of  the  intestine. 

3.  Obstruction  from  tumors  and  foreign  bodies. 

4.  Compression  by  tumors  from  without,  etc. 

A  glance  at  the  foregoing  schema  will  convince  any  one  that  a 
clearer  classification  of  intestinal  obstruction  is  greatly  needed  in 
order  to  harmonize  the  views  of  physicians  and  surgeons  and  so  fur- 
nish them  with  a  more  reliable  guide  in  formulating  rational  plans 
for  the  treatment  to  be  pursued.  For  the  physician  it  is  most  impor- 
tant to  differentiate,  as  early  as  possible,  between  mechanical  and 
dynamic  obstruction — in  other  words,  to  separate  the  cases  into  med- 
ical and  surgical ;  for  the  surgeon  it  is  imperative  that  he  should 
know  the  nature  and  location  of  the  mechanical  obstruction  before 
he  resorts  to  the  knife.  For  these  reasons  it  has  been  deemed  ad- 
visable to  discuss  the  different  forms  of  intestinal  obstruction  from 
an  anatomicopathologic  standpoint.  While  the  different  pathologic 
forms  of  chronic  and  acute  obstruction  present  many  features  in 
common,  the  clinical  picture  is  usually  materially  modified  by  the 
anatomic  location  of  the  obstruction,  and  certainly  when  this  location 
can  be  determined  before  the  abdomen  is  opened,  the  surgeon  is 
better  prepared  to  outline  beforehand  the  operative  treatment  that  is 
to  be  pursued.  The  experience  of  Curschmann,  Naunyn,  Goltdam- 
mer,  and  other  distinguished  physicians  has  shown  that  about  one- 
third  of  all  cases  of  intestinal  obstruction  will  recover  under  rational 
internal  treatment,  and  these  are  the  cases  that,  with  few  exceptions, 
are  due  to  dynamic  causes.  It  seems,  then,  that  about  one  case  in 
three  has  a  chance  of  recovery  without  operation  under  medical 
treatment.  Dynamic  obstruction  is  due  most  frequently  to  periton- 
itis ;  next  in  frequency,  to  reflex  intestinal  paralysis ;  and,  finally,  to 
intestinal  spasm — enterospasm. 

It  is  not  always  easy  or  possible  to  differentiate  between  dynamic 
and  mechanical  obstruction  ;  there  are,  however,  certain  symptoms 
that  are  very  significant  of  each  and  that  must  be  studied  with  the 
greatest  care.  Peritonitis  is  characterized  by  diffuse  tympanites, 
tenderness,  fever,  rapid,  wiry  pulse.  Fever  is  not  constantly  present 
in  peritonitis,  as  in  the  gravest  forms  the  temperature  is  not  infre- 
quently subnormal.  Vomiting,  so  constant  a  symptom  in  both  the 
mechanical  and  dynamic  forms  of  obstruction,  often  becomes  fecal 
in  peritonitis  when  the  inflammation  and  adhesions  of  the  intestinal 


STRANGULATION.  849 

wall  result  in  dynamic  obstruction.  Dynamic  obstruction  due  to 
intestinal  paralysis  without  inflammation  is  of  rare  occurrence,  and 
its  nature  is  as  yet  very  imperfectly  known.  It  is  probable  that  some 
of  the  cases  of  intestinal  obstruction  after  laparotomy  have  such  an 
origin.  Heidenhain  reports  from  the  Greifswald  clinic  three  cases 
of  enterospasm  out  of  thirty  cases  of  intestinal  obstruction.  All 
recovered.  In  one,  laparotomy  was  performed,  but  no  obstruction 
was  found.  In  all  the  cases  the  existence  of  a  local  irritation  was 
considered  as  the  cause  of  the  localized  spasm.  He  refers  to  similar 
cases  in  the  practice  of  James  Israel  and  Korte.  In  all  cases  of 
obstruction  due  to  enterospasm  or  paralysis  without  inflammation 
the  constitutional  s)-mptoms  were  not  severe,  a  clinical  feature  of 
great  importance  as  compared  with  mechanical  obstruction  or  ob- 
struction due  to  inflammation.  No  surgeon  questions  the  fact  that 
in  very  rare  cases  a  slight  invagination  or  volvulus  is  corrected  .spon- 
taneously or  by  rectal  inflation,  but  these  cases  arc,  to  say  the  lea.st, 
exceptional.  We  are,  therefore,  forced  to  the  conclu.sion  that  all 
cases  of  mechanical  ob-struction  are  surgical  affections  from  the  very 
beginning,  and  must  be  treated  as  such  within  from  twenty-four  to 
forty-eight  hours  if  the  patient  is  to  receive  the  benefits  from  an  early 
operation  to  which  he  is  entitled.  Irregularity  of  the  contour  of  the 
abdomen,  localized  tympanites  and  resistance,  absolute  interception 
of  gas  and  fecal  matter,  visible  or  palpable  intestinal  peristalsis,  and 
fecal  vomiting  are  some  of  the  .symptoms  most  relied  upon  in  differ- 
entiating mechanical  from  dynamic  obstruction.  The  pulse  at  first 
is  but  little  affected.  In  volvulus  the  pulse  has  been  frequently 
reduced  to  less  than  sixty  (Heidenhain).  Fecal  vomiting  is  seen 
not  infrequently  during  the  latter  stages  of  peritonitis.  Arrest  of 
intestinal  contents  is  often  incomplete  in  invagination.  Visible  or 
palpable  peristalsis  is  more  con.stant  in  obstruction  from  obturation, 
strictures,  twists,  impaction  from  tumors  and  foreign  bodies,  or 
obstruction  from  compression. 

The  clinical  symptoms  most  characteristic  of  strangulation  ob- 
struction, volvulus,  band  constriction,  internal  hernia,  and  invagi- 
nation are  appreciable  asymmetry  of  the  abdominal  surface,  local- 
ized resistance,  paresis  of  the  strangulated  loop  lying  against  the 
abdominal  wall,  and  the  absence  of  stormy  peristalsis.  The  clinical 
histoiy  is  of  much  import  in  searching  for  the  nature  and  location 
of  tiie  obstruction.  Age,  .sex,  antecedent  abdominal  affections, 
previous  condition  of  the  fecal  di.scharges,  and  tlie  general  pliy.si(|ue 
of  the  patient  mu.st  all  be  taken  into  careful  consideration  before 
the  .symptoms  pre.sented  at  the  bedside  are  analyzed  and  classified. 

The  weak  side  of  intestinal  surgery  to-day  is  the  uncertainty  of 
diagno.sis ;  the  surgeon  mu.st  often  shoulder  the  responsibility 
imjjosed  upon  him  by  the  present  .status  of  modern  a.septic  surgery 
of  .seeking  light  in  doubtful  cases  by  resorting  to  an  exploratory 
incision,  and  then  acting  in  accordance  with  what  is  revealed  by 
in.spection  and  palpation, 
54 


850  VOLVULUS. 

Volvulus. — Volvulus  constitutes  a  well-defined  and  definite  ana- 
tomic form  of  intestinal  obstruction.  This  term  is  used  to  designate 
that  form  of  impermeability  of  the  intestinal  canal  that  results  from 
twisting  or  rotation  of  one  or  more  loops  of  the  bowel  about  its 
mesenteric  axis. 

Frequency  of  its  Occurrence. — Volvulus,  as  compared  with  some 
other  forms  of  intestinal  obstruction,  is  quite  rare,  constituting  about 
4  per  cent.  In  1541  cases  of  obstruction  from  different  causes  col- 
lected by  Leichtenstern  and  analyzed  with  special  reference  to  the 
anatomic  cause  of  the  obstruction,  after  deducting  178  due  to  car- 
cinoma, 33  cases  only  were  due  to  twisting  of  the  bowel,  including 
twists  of  both  the  sigmoid  flexure  and  the  ileum.  The  same  author 
also  gives  the  result  of  his  examinations  of  76  cases  of  volvulus  that 
he  has  collected,  and  of  this  number  the  lesion  was  found  in  45 
cases  in  the  sigmoid  flexure,  in  23  cases  in  the  ileum,  and  in  8  cases 
in  the  jejunum  and  ileum  combined  (Plate  6). 

Predisposing  Causes. — Volvulus  occurs  more  frequently  in  the 
male  than  in  the  female,  the  proportion  being  about  four  to  one. 
A  larger  mesentery  in  the  male  and  more  violent  exertions  are  the 
probable  causes  that  explain  this  difference.  It  is  met  more  fre- 
quently in  persons  advanced  in  years,  the  average  age  being  about 
fifty  ;  no  age,  however,  is  exempt,  and  it  has  been  observed  as  a 
congenital  affection. 

G.  Fischer  found  a  most  interesting  specimen  of  congenital  vol- 
vulus in  a  child  that  died,  three  days  after  birth,  with  symptoms  of 
intestinal  obstruction.  An  operation  for  imperforate  anus  was  made 
soon  after  the  child  was  born.  The  postmortem  showed  intestinal 
atresia  and  volvulus.  The  narrowing  of  the  intestine  commenced  at 
the  middle  of  the  ileum,  and  from  there  extended  the  whole  length 
of  the  intestinal  canal.  In  some  places  the  intestine  was  represented 
by  a  solid  cord  ;  in  other  places  the  lumen  was  reduced  to  the  size 
of  a  quill.  The  appendix  was  found  attached  to  the  contracted 
colon  at  a  point  where  it  was  slightly  dilated,  but  without  a  sign  of 
a  cecum.  About  the  middle  of  the  contracted  portion  of  the  small 
intestine  a  loop  had  become  twisted  twice  around  its  mesenteric  axis, 
and  showed  distinct  evidences  of  strangulation.  No  indications  of 
intra-uterine  peritonitis. 

Volvulus  can  occur  only  when  the  mesentery  of  the  bowel  is  of 
abnormal  length,  and  is,  therefore,  most  frequently  met  in  the  seg- 
ments of  the  intestinal  tract  normally  provided  with  a  long  mesen- 
tery, as  the  sigmoid  flexure  and  the  lower  part  of  the  ileum. 

Volvulus  of  the  cecum  can  occur  only  when  it  is  supplied  with 
a  mesentery  common  with  the  ileum — that  is,  in  the  event  of  an 
arrest  of  development  in  which  the  mesenteric  plate  of  the  cecum 
does  not  become  attached  to  the  posterior  abdominal  wall.  Dreike 
found  such  a  common  mesentery  quite  frequently  in  postmortems 
made  on  children  in  the  orphan  asylum  at  Mosthon,  and  von  Zoege- 
Manteuffel  found  in   the  literature  twenty  cases  of  volvulus  of  the 


Plate  6. 


\ 


Volvulus  of  sigmoirl  flexure.     Twist  one  and  one-half  arouiul  nicseniciii-  axis.      (Iicat 
(listcntiuii  and  vascularity  of  twisted  loop. 


PREDISPOSING    CAUSES.  85  I 

cecum,  and  four  additional  cases  that  came  under  his  own  obser- 
vation, or  these  four  cases  all  were  treated  by  laparotomy,  three 
recovering,  but  the  fourth  dying  of  peritonitis,  which  had  set  in 
before  the  operation  was  performed. 

James  Israel  calls  special  attention  to  contracting  mesenteritis  as 
a  predisposing  cause  of  volvulus  of  the  sigmoid  flexure.  In  several 
cases  he  found  that  the  mesocolon  of  the  sigmoid  flexure  had  been 
narrowed  so  much  from  this  cause  that  the  limbs  of  the  flexure 
were  brought  almost  in  contact  at  the  base  of  the  volvulus.  As  to 
the  immediate  or  exciting  cause,  he  believes  that  distention  of  the 
bowel  plays  an  important  part.  If  the  distention  is  on  the  proximal 
side,  the  upper  limb  is  thrown  around  the  rectal  portion.  "  Type 
rectum  eti  arriere"  (Potain),  while  the  reverse,  '"Type  rectiini  e)i 
avant"  takes  place  if  the  distention  is  on  the  opposite  side.  In  one 
of  his  cases  the  latter  form  could  be  traced  to  a  high  enema. 

I  found  it  almost  impossible  to  produce  and  maintain  a  complete 
volvulus  in  dogs  and  cats,  owing  undoubtedly  to  the  shortness  of 
the  mesentery.  The  volvulus  was  experimentally  produced  by 
rotating  a  loop  of  intestine  one  and  a  half  or  two  times  around  its 
axis,  and  retaining  it  in  this  position  by  a  number  of  fine  sutures, 
which  were  applied  in  places  at  the  base  of  the  volvulus,  where  fix- 
ation was  most  required. 

Experiment  ii. — Dog,  weight  twelve  pounds.  A  loop  of  the  ileum  eight  inches 
in  length  was  brought  out  through  a  small  incision,  and  the  tubes  turned  around  their 
axis  twice  and  the  twist  maintained  by  two  catgut  sutures.  The  constriction  was  suffi- 
cienUy  firm  to  cause  considerable  venous  engorgement  in  the  twisted  loop.  The  dog  mani- 
fested no  unpleasant  symptoms  after  the  operation.  The  specimen  was  not  obtained,  as 
after  a  few  days  the  dog  ran  away. 

Experiment  12. — Medium-sized  adult  cat.  In  this  case  the  volvulus  was  made 
by  twisting  a  loop  of  the  ileum  about  four  inches  in  length  twice  around  its  axis,  and  re- 
taining it  in  this  position  by  a  number  of  fine  silk  sutures.  Vomited  several  times  during 
the  first  day.  The  first  three  days,  in  taking  the  temi^crature  in  the  rectum,  the  ther- 
mometer when  taken  out  was  bloody.  The  lirst  two  days  the  lem])eratiire  was  normal, 
followed  by  an  increase  to  104.6°  F.  and  103.2°  F.  respectively,  tlie  two  succeeding 
days;  then  it  became  normal.  No  constipation;  appetite  good  throughout  the  whole 
time.  Animal  killed  twenty-two  days  after  operation.  Abdominal  wound  completely 
united  ;  no  peritonitis.  Volvulus  remains  as  after  operation,  with  the  exception  that 
where  the  bowel  had  been  flattened  by  the  twisting  it  had,  at  least  partially,  resumed  its 
tubular  form.  Serous  surfaces  where  apjjroximated  had  become  firmly  adherent  at  point 
of  constriction  ;  size  of  bowel  considerably  diminished.  The  twisted  loop  contained 
liquid  feces.  Connecting  the  specimen  with  the  faucet  of  a  hydrant,  water  could  be 
forced  through,  but  on  increasing  the  force  of  the  current  the  peritoneum  ruptured  exten- 
sively in  a  longitudinal  direction  to  point  of  partial  obstruction. 

The.se  cxpenmcnts  arc  interesting,  inasmuch  as  the  primary  con- 
striction produced  in  making  and  maintaining  the  volvulus,  which 
was  sufficient  to  cause  venous  engorgement  in  the  twi.sted  loop, 
mu.st  have  been  of  only  short  duration,  the  di.sappearance  ot  the 
effects  of  constriction  being  undoubtedly  <\v\(t  to  the  gradual  yielding 
of  the  sutured  parts  ;  while  the  faulty  axis  of  the  twisted  loop  was 
maintained  by  the  sutures,  the  circulation  improved  and  remained 
in  a  sufficiently  vigorous  condition  aderiuately  to  notnisli  the  most 
distant  portions  of  the  volvulus.  While  it  was  found  difficult  dur- 
ing life  to  force  fluid  through  the  specimen  of  a  volvulus,  propulsion 


852  VOLVULUS. 

of  the  intestinal  contents  by  peristaltic  action  was  carried  on  in  a 
satisfactory  manner,  as  the  bowel  above  the  volvulus  was  not  dilated 
and  contained  no  abnormal  amount  of  fluid,  and  the  animal  mani- 
fested no  symptoms  indicative  of  intestinal  obstruction. 

That  the  relation  of  the  length  of  the  intestinal  canal  to  the 
mesentery  exerts  some  influence  in  the  causation  of  volvulus  has 
been  well  shown  by  Kiittner.  He  ascertained,  from  his  anatomic 
researches,  that  in  persons  who  subsist  almost  exclusively  on  coarse 
vegetable  food,  as  is  the  case  with  most  of  the  peasants  in  Russia, 
the  small  intestine  measures  from  twenty  to  twenty-seven  feet  in 
length,  while  in  persons  of  German  birth  the  length  varies  between 
seventeen  and  nineteen  feet.  The  same  author  has  also  shown  that 
volvulus  is  much  more  frequently  met  in  Russia  than  in  Germany. 
As  the  mesenteric  attachment  to  the  posterior  abdominal  wall  must 
be  nearly  the  same  in  all  individuals,  so  far  as  its  extent  is  con- 
cerned, the  occurrence  of  volvulus  will  be  favored  in  proportion  to 
the  length  of  the  intestinal  canal.  The  nearer  the  two  bars  of  an 
intestinal  loop  approach  each  other,  the  narrower  the  mesentery 
and,  therefore,  the  greater  the  risk  of  rotation  about  its  axis 'from 
causes  that  disturb  the  peristaltic  movements.  Sudden  or  gradual 
elongation  of  the  intestinal  canal  from  distention,  as  we  observe  it 
in  cases  of  intestinal  obstruction  and  peritonitis,  furnishes  one  of 
the  mechanical  conditions  upon  which  the  production  of  volvulus 
depends,  by  disturbing  the  normal  relations  that  exist  between  the 
length  of  the  intestines  and  their  fixed  points  of  attachment.  It  is 
not  uncommon  to  find,  in  postmortem  records  of  persons  who  have 
died  of  peritonitis,  mention  of  volvulus  as  a  secondary  condition, 
and  in  cases  of  intestinal  obstruction  it  is  by  no  means  rare  to  find 
the  same  condition  as  a  secondary  occurrence  on  the  proximal  side 
of  the  primary  occlusion. 

I  have  met  volvulus  in  two  of  my  abdominal  sections,  where 
this  lesion  could  be  accounted  for  only  by  attributing  it  to  elonga- 
tion of  the  intestines  from  distention.  In  one  case  it  followed  a 
strangulated  hernia.  The  patient  was  a  young  man  who  had 
suffered  for  a  week  from  a  strangulated  inguinal  hernia.  On  open- 
ing the  sac  the  strangulated  loop  was  found  to  be  gangrenous  ;  the 
incision  was  therefore  enlarged  in  an  upward  direction,  and  the 
bowel  brought  down  until  healthy  tissue  was  reached.  The  part 
of  the  intestine  leading  downward  was  collapsed,  while  the  portion 
on  the  proximal  side  was  only  moderately  distended.  As  this 
amount  of  distention  did  not  explain  the  general  diffuse  tympanites, 
it  was  deemed  necessary  to  search  for  an  additional  cause  of  ob- 
struction higher  in  the  intestinal  canal.  The  abdomen  was  opened 
by  enlarging  the  incision  in  an  upward  direction.  About  one  foot 
above  the  seat  of  strangulation  a  mass  of  intestinal  coils  was  found 
twisted  upon  their  mesenteric  attachments  and  firmly  adherent. 
Above  this  secondary  obstruction  the  intestines  Avere  enormously 
distended  and  very  much  congested.      In  this  case  the  distention  of 


PREDISPOSING    CAUSES.  853 

the  intestine,  commencing  at  the  internal  inguinal  ring,  had  caused 
elongation  of  the  bowel,  which  in  turn  resulted  in  volvulus,  oivino- 
rise  to  a  speedy  aggravation  of  the  symptoms  of  obstruction. 
That  the  volvulus  was  not  of  long  standing  was  evident  from  the 
fact  that  the  adhesions  were  recent,  and  limited  to  the  part  of  the 
intestine  implicated  in  the  twist. 

In  m}-  second  case  the  volvulus  formed  after  perforation  of  a 
typhoid  ulcer.  The  patient  was  seen  three  days  after  the  perforation 
had  occurred,  and  at  that  time  the  symptoms  pointed  rather  to  vol- 
vulus than  to  perforation  and  peritonitis.  The  abdomen  was  opened 
and  the  volvulus  readily  found.  A  number  of  loops  of  the  small 
intestine  had  undergone  a  complete  twist  around  the  mesenteric  axis, 
and  showed  evidences  of  strangulation,  and  were  at  the  same  time 
enormously  dilated.  The  diffuse  septic  peritonitis  that  was  present 
had  been  caused  by  perforation  of  a  typhoid  ulcer  a  few  inches 
above  the  ileocecal  valve.  The  perforation  was  closed  by  suturing, 
the  volvulus  corrected,  and  the  abdominal  cavit}'  flushed  with  a  weak 
solution  of  salicylic  acid.  The  patient  never  rallied  fully  from  the 
shock,  and  died  a  few  hours  after  the  operation. 

Nieberding  has  recently  called  attention  to  another  cause  of  vol- 
vulus. He  has  reported  a  case  that  occurred  in  Bumm's  practice, 
where,  after  an  ovariotomy,  a  volvulus  of  the  small  intestine  occurred 
that  proved  fatal  after  a  few  days.  During  the  operation  the  omen- 
tum, which  was  adherent  to  the  cyst,  was  separated  and  a  portion 
excised.  The  necropsy  showed  that  the  raw  surface  of  the  omental 
stump  had  formed  an  adhesion  to  a  loop  of  the  small  intestine,  and 
above  the  fixed  point  a  voUulus  was  found.  He  reported  another 
and  somewhat  similar  case  that  had  come  under  his  own  observation. 
A  large  cystosarcoma  of  the  left  ovary  was  removed  in  a  woman 
twenty-nine  years  of  age.  Before  closing  the  wound  it  was  noticed 
that  the  omentum  was  so  short  that  the  intestines  could  not  be  cov- 
ered by  it  in  the  region  of  the  incision.  v\t  the  end  of  the  second 
day  symptoms  of  acute  obstruction  set  in,  the  temperature  re- 
maining normal.  As  the  .symptoms  increased  in  gravity  and  the 
ordinar)'  treatment  proved  fruitless,  the  wound  was  opened,  and  a 
loop  of  intestine  was  found  arlherent  to  the  left  margin  of  the  incision, 
and  after  this  .separated  a  volvulus  was  detected.  The  bcnvel  was 
untwisted  and  its  contents  forced  into  the  segment  further  down, 
beyond  the  .seat  of  obstruction,  the  detached  loop  i)uslied  beyond 
the  reach  of  the  abdominal  wound,  and  the  abdomen  closed.  The 
day  after  the  operation  the  intestinal  canal  api)eared  to  be  permeable, 
gas  escaping  per  rectum,  but  evidences  of  peritonitis  set  in  and  the 
patient  died  with  .symptoms  of  collapse. 

From  the  foregoing  considerations  it  is  apparent  that  the  follow- 
ing three  mechanical  conditions  favor  rotation  of  the  intestine  about 
its  mesenteric  axis  : 

(l)  Long  mesentery;  (2)  phy.siologic  or  pathologic  elongation 
of  the  bowel  ;  (3)  intestinal  adhesions  to  the  abdominal  wall. 


854  VOLVULUS. 

Exciting  Causes. — Among  the  exciting  causes  of  volvulus 
Kiittner  mentions,  as  the  most  important,  unequal  distribution  of 
intestinal  contents  and  exaggerated  peristalsis.  He  never  observed 
peritonitis  in  any  of  his  cases,  even  if  life  was  prolonged  for  five  or 
six  days.  He  asserts  that  the  complicated  forms  of  knotting  of  the 
intestines,  which  are  still  described  in  the  text-books  as  rare  but 
distinct  forms  of  obstruction,  are  only  varieties  of  volvulus.  Gra- 
witz  asserts  that  the  immediate  cause  of  volvulus  is  to  be  found  in 
an  accumulation  of  intestinal  contents  above  a  constricted  portion 
of  bowel ;  that  the  distended  portion  of  intestine  above  the  seat 
of  constriction  undergoes  elongation,  and  that  this  elongated  por- 
tion then  rotates  around  its  axis.  Henning  firmly  ligated  the  intes- 
tines of  animals,  and  injected  water  above  the  seat  of  obstruction. 
In  the  small  intestine  the  distended  and  elongated  coils  above  the 
ligature  always  showed  a  tendency  to  rotate  upon  their  vertebro- 
mesenteric  axes,  thus  producing  a  volvulus.  In  the  large  intestine, 
on  account  of  the  shortness  of  the  mesenteric  attachment,  the  same 
experiment  caused  rupture  of  the  bowel  before  a  volvulus  could  be 
produced.  These  experiments  furnish  positive  evidence  that  volvu- 
lus of  the  large  intestine  can  not  occur  when  the  mechanical 
conditions  described  as  predisposing  causes  are  absent.  Henning 
collected  a  number  of  cases  of  volvulus  scattered  through  the  liter- 
ature on  this  subject,  where,  in  the  postmortem  description  of  the 
twisted  bowel,  it  was  distinctly  stated  that  the  lumen  of  the  intestine 
was  narrowed  by  some  form  of  acquired  or  congenital  stenosis, 
which  is  only  another  proof  in  support  of  the  statement  that  elonga- 
tion of  the  bowel  constitutes  one  of  the  most  important  conditions 
in  the  causation  of  this  form  of  intestinal  obstruction.  Violent 
peristalsis,  caused  by  intestinal  indigestion,  some  form  of  chronic 
obstruction,  or  some  kind  of  violent  exertion  in  which  the  abdominal 
muscles  are  especially  concerned,  is  usually  the  immediate  cause  of 
the  torsion. 

Spontaneous  Reposition. — We  have  reason  to  believe  that  a 
violent  peristalsis  not  infrequently  produces  a  volvulus,  but  when 
the  bowel  and  its  mesentery  are  of  normal  length,  spontaneous 
reduction  occurs  as  soon  as  the  peristaltic  wave  has  passed.  Such 
a  condition  gives  rise  to  abdominal  pain  and  a  temporary  disturb- 
ance of  the  fecal  movement.  In  animals  in  which  volvulus  was 
produced  artificially  by  twisting  an  intestinal  loop  completely  around 
its  axis  and  fixing  it  in  this  position  by  suturing,  complete  obstruc- 
tion was  never  produced,  and  it  was  usually  found,  subsequently, 
that  partial  reposition  had  been  effected  by  gradual  yielding  of  the 
sutures  and  adhesions.  The  conditions  are  entirely  different  when 
both  the  intestine  and  the  mesentery  are  abnormally  long,  under 
which  circumstances  spontaneous  reposition  seldom,  if  ever,  takes 
place.  In  such  cases  the  mechanical  obstruction  caused  by  the 
twist  is  soon  followed  by  dynamic  obstruction  in  the  segment  of 
bowel  constituting  the  volvulus,  caused  by  the  pathologic  conditions 


SYMPTOMS    AND    DIAGNOSIS.  855 

arising  from  the  strangulation.  The  mechanical  constriction  that 
takes  place  at  the  point  of  rotation  produces  paresis,  venous 
engorgement,  edema,  and  gangrene.  These  secondary  conditions 
are  followed  by  distention  of  the  intestine  and  accumulation  of  intes- 
tinal contents,  which  can  not  fail  to  aggravate  the  mechanical  diffi- 
culties that  initiated  the  obstruction. 

Symptoms  and  Diagnosis. — Primary  volvulus  is  of  sudden 
occurrence,  and  when  located  anywhere  above  the  ileocecal  valve, 
is  usually  attended  by  severe  pain  and  other  symptoms  of  acute 
obstruction.  Vomiting  is  a  prominent  symptom  in  volvulus  of  the 
small  intestine,  but  is  often  entirely  absent  when  the  colon  is  the  seat 
of  the  twist. 

Poppert  reports  a  case  of  volvulus  of  the  sigmoid  flexure,  which 
had  become  twisted  180  degrees  around  its  mesenteric  axis,  where 
vomiting  never  occurred  from  the  beginning  of  the  attack  to  the 
fatal  termination.  He  also  refers  to  the  statement  made  by  Roser, 
that  in  cases  of  volvulus  of  this  portion  of  the  colon,  vomiting  is  a 
late  symptom,  or  may  be  entirely  wanting.  Treves  found  that  this 
symptom  was  absent  in  three  out  of  twenty  cases  of  volvulus  that 
he  collected. 

In  Poppert's  case  it  was  shown  during  life,  by  the  introduction 
of  an  elastic  tube  through  which  the  organ  was  washed  out,  that 
the  stomach  was  empty  or  nearly  so.  In  volvulus  of  the  sigmoid 
flexure  the  pain  is  often  referred  to  the  umbilical  region,  and  not  to 
the  seat  of  the  obstruction.  A  circumscribed  area  of  tenderness 
over  the  surface  corresponding  to  the  circumference  of  the  twisted 
loop  is  an  early  and  well-marked  symptom.  A  volvulus  once  fully 
developed  gives  rise  to  complete  obstruction,  the  violent  peri.stalsis 
above  the  seat  of  obstruction  aiding  in  rendering  the  occlusion  more 
complete.  Diffuse  peritonitis  is  never  met  with  in  cases  of  volvulus 
unless  it  has  developed  in  consccpience  of  gangrene  or  perforation. 
Localized  plastic  peritonitis  is,  however,  of  frequent  occurrence, 
commencing  in  the  twisted  mesenteiy  and  extending  from  that  to 
the  intestine.  Such  adhesions  in  cases  where  a  number  of  loops 
are  implicated  in  the  volvulus,  or  where  knotting  of  the  intestine 
has  taken  place,  frequently  offer  .serious  difficulties  in  effecting  repo- 
sition, and,  after  successful  reposition,  tend  to  reprtjduce  the  volvu- 
lus unless  provi.sion  is  made  by  special  measures  against  such  an 
occurrence.  The  occurrence  of  gangrene  of  the  twisted  loop  is 
announced  by  a  small,  rapid,  feeble  pulse  and  other  symptoms  indic- 
ative of  septic  intoxication.  Professor  von  Wahl  has  called  special 
attention  to  an  imi)fjrtant  early  diagnostic  .sign  in  cases  of  strangu- 
lation and  volvulus.  Schweninger's  experimental  investigations 
have  shown  that  meteori.smus  fir.st  takes  place  in  the  constricted  or 
twi.sted  loops  of  the  bowel,  and  von  VV^ilil  has  in  a  number  of  cases 
been  able  to  make  a  positive  diagnosis  of  volvulus  by  pcrcu.ssion, 
by  which  he  located  a  circumscril)ed  area  of  tympanites,  which,  on 
opening  the  abdomen,  was  found  to  corresponti  to  the  site  of  the 


856  VOLVULUS, 

twisted  and  dilated  loop.  As  volvulus  occurs  usually  in  some  por- 
tion of  the  colon  or  the  lower  portion  of  the  ileum,  its  exact  location 
can  be  readily  determined  by  rectal  insufflation  of  hydrogen  gas  or 
air.  This  diagnostic  measure  is  of  the  greatest  importance  and 
value  before  general  tympanites  has  set  in.  If  the  volvulus  is 
located  at  the  sigmoid  flexure,  only  a  small  quantity  of  gas  can  be 
introduced,  and  after  the  distention  of  the  colon  below  the  seat  of 
obstruction,  the  localized  tympanites  due  to  the  volvulus  will  be 
found  a  little  higher  up  in  the  abdomen,  the  twisted  loop  of  the 
bowel  having  been  pushed  in  an  upward  direction  by  the  distended 
colon.  If  the  cecum  is  the  seat  of  the  volvulus,  the  insufflation 
can  be  continued  until  the  entire  colon  is  fully  distended,  but  the 
gas  can  not  be  forced  into  the  small  intestine.  The  effect  of  the 
insufflation  under  such  circumstances  will  be  to  widen  the  abdomen 
without  increasing  its  prominence.  If  the  volvulus  is  situated  above 
the  ileocecal  valve,  the  gas  will  rush  from  the  colon  into  the  ileum 
with  an  audible  blowing  or  gurgling  sound,  and  the  distention  of  the 
lower  coils  of  the  small  intestine  will  cause  the  hypogastric  region 
to  become  more  prominent. 

In  recapitulation  it  may  be  said  that  the  most  important  symp- 
toms and  signs  upon  which  a  probable  or  positive  diagnosis  can  be 
based  are  the  following:  (i)  Suddenness  of  attack;  (2)  absolute 
obstruction  ;  (3)  localized  area  of  tympanites  ;  (4)  permeability  of 
intestinal  canal  to  rectal  insufflation  of  hydrogen  gas  or  air  as  far  as 
the  seat  of  obstruction.  The  localized  swelling,  tympanites,  and  ten- 
derness over  the  twisted  intestinal  loop  are  symptoms  of  the  utmost 
value  soon  after  the  accident  has  occurred  ;  later  these  symptoms 
are  overshadowed  and  obscured  by  the  more  diffuse  tympanites 
caused  by  the  distention  of  the  bowel  above  the  obstruction. 

Prognosis. — A  fully  developed  volvulus — that  is,  a  half  to  two 
complete  twists — taking  place  in  a  portion  of  the  intestine  predis- 
posed to  such  an  occurrence  by  congenital  or  acquired  causes  is 
never  corrected  without  direct  mechanical  assistance,  and,  if  left  to 
itself,  invariably  results  in  death  within  a  short  time  from  intestinal 
obstruction,  gangrene,  or  septic  peritonitis.  The  acuteness  of  symp- 
toms and  the  immediate  danger  to  life  increase  as  the  volvulus 
approaches  the  upper  portion  of  the  intestinal  canal.  Death  results 
either  from  exhaustion,  owing  to  the  incessant  vomiting  and  defec- 
tive nutrition,  or  from  the  pathologic  changes  that  occur  in  the 
twisted  portion  of  the  bowel ;  the  latter  consist  in  gangrene  affecting 
the  entire  loop  or  circumscribed  gangrenous  spots  at  the  point  of 
greatest  pressure,  resulting  in  perforation  and  septic  peritonitis.  As 
the  gangrene  is  the  result  of  pressure  or  strangulation,  its  rapid 
occurrence  may  be  expected  when  the  twist  is  tight — that  is,  when 
the  intestinal  loop  has  been  rotated  once  or  twice  around  its  mesen- 
teric attachment.  Death  from  any  of  these  causes  may  occur  in  a 
few  days,  and  life  is  seldom  prolonged  for  more  than  a  week. 

Treatment. — A  violent  peristalsis  is  not  only  one  of  the   causes 


TREATMENT. 


of  volvulus,  but  also  a  condition  that  serioush'  aggravates  the  local 
and  general  conditions  after  the  accident  has  occurred,  one  of  the 
first  nidications  of  treatment  should  be  to  place  the  bowel  as  nearly 
as  possible  in  a  condition  approaching  physiologic  rest.     No  food 
should  be  introduced  into  the  stomach,  and  thirst  should  be  quenched 
by  small  pieces  of  ice.      If  the  vomiting  is  severe,  or  if  this  symptom 
IS  absent  and  there  is  reason  to  believe  that  the  stomach  is  not 
empty,  washing  out  of  the  organ  by  means  of  a  flexible  tube  is 
mdicated.  this  simple  procedure  being  often  followed  by  immediate 
and  great  relief     The  peristalsis  is  quieted  by  the  administration  of 
some  preparation  of  opium,  and  if  this  is  not  retained  by  the  stomach 
morphin  is  administered    hypodermically.      The   bowel   below  the 
volvulus  IS  evacuated  by  copious  injections,  which  should  be  given 
while  the  patient  is  placed  in  Hegar's  knee-chest  position.      The 
patient  is  to  be  nourished  exclusively  by  rectal  enemata.     Are  there 
any  known  means  by  which  reposition  can  be  effected  without  open- 
ing the  abdomen?     Jonathan   Hutchinson,  whose  \iews  concerning 
the  utility  of  laparotomy  in  the  treatment  of  intestinal  obstruction 
are,  to  say  the  least,  exceedingly  pessimistic,  in  a  paper  on  "  Records 
of  Intestinal  Obstruction,  with  Especial  Reference  to  Symptoms  and 
Treatment"  ("Archives  of  Surgery,"  vol.  i,  No.  i),  again  calls  atten- 
tion to  the  value  of  his  method  of  performing  abdominal  taxis  in 
the  treatment  of  intestinal  obstruction,  irrespective  of  a  probable  or 
positive  anatomic  diagnosis.      His  method  is  described  as  follows  : 
"The  first  point  in  abdominal  taxis  is  the  full  use  of  an  anesthetic, 
so  as  to   obliterate   all  muscular   action,   repeatedly  kneading   the 
abdomen,  pressing  its  contents  vigorously  upward,  downward,  and 
from  side  to  side.      The  patient  is  now  to  be  turned  on  his  abdomen, 
and  in  this  position  to  be  held  up  by  four  strong  men,  and  shaken 
backward  and  forward.     This  done,  tlie  trunk  is  to  be  held  upper- 
most, and  shaking  again  practised  directly  upward  and  downward  ; 
while  in  this  position  copious  enemata  are' to  be  given.     The  whole 
proceedings  are  to  be  carried  out  in  a  bona  fide  and  energetic  man- 
ner.     It  is  not  to  be  merely  the  name  of  taxis,  but  the  reality,  and 
patience  and  persistence  are  to  be  exercised.      The  inversion  of  the 
body  and  succussion  in  this  position  are  on  no  account  to  be  omitted, 
for  they  are  po.ssibly  the  most  important  of  all.      I  do  not  think  that 
I  ever  .spend  less  than  half  or  three-quarters  of  an  hour  in  the  pro- 
cedure." 

As  Mr.  Hutchinson  mentions  no  exceptions,  so  far  as  the  nature 
of  the  obstruction  is  concerned,  we  have  reason  to  believe  tiiat  he 
advises  taxis,  as  described,  in  the  treatment  of  volvulus.  Taxis  has 
a  limited  field  of  useful  application  in  some  forms  of  intestinal  ob- 
struction, but  in  the  treatment  of  volvulus  it  mii.st  be  looked  upon 
not  only  as  a  useless,  but  also  as  an  exceedingly  dangen^us,  per- 
formance. It  is  difficult  to  conceive  in  what  manner  such  gymnastic 
exercises  could  effect  reposition,  while  it  is  easy  to  understand  in 
what  manner  the  different  movements  would  increase  the  rotation. 


858  VOLVULUS. 

Furthermore,  volvulus  is  rapidly  followed  by  textural  changes  that 
weaken,  and  finally  destroy,  the  intestinal  walls  ;  and  hence  taxis, 
as  advised  and  practised  by  Mr.  Hutchinson,  would  expose  the 
patient  to  the  imminent  risk  of  producing  a  rupture  of  the  bowel, 
without  promising  the  shadow  of  a  hope  that  reposition  would  be 
accomplished.  Only  one  mechanical  measure  suggests  itself  as 
offering  any  inducements  in  effecting  the  reposition  of  volvulus  short 
of  laparotomy.  Rectal  insufflation  of  hydrogen  gas  or  air  has 
already  been  referred  to  as  a  diagnostic  measure.  In  some  cases  of 
volvulus  the  rotation  of  the  bowel  around  the  vertebromesenteric 
axis  is  often  less  than  one  complete  circle,  and  before  the  loop  has 
become  considerably  changed  by  the  twist,  a  reduction  might  be 
effected  by  dilating  and  elongating  the  bowel  below  the  seat  of 
obstruction,  thus  bringing  the  same  causes  to  bear  that  have  pro- 
duced the  displacement,  but  in  an  opposite  direction.  In  the  majority 
of  cases  the  twist  is  made  by  violent  peristalsis  on  the  proximal 
side,  the  ''Type  rectiun  en  arria^e,"  and  then  the  distention  of  the 
bowel  below  the  volvulus  would  have,  in  the  absence  of  adhesions, 
a  decided  influence  in  correcting  the  torsion.  This  method  of 
reduction  should  be  practised  with  great  care,  and  is,  of  course, 
applicable  only  in  recent  cases,  before  the  appearance  of  general 
tympanites  and  before  the  bowel  has  undergone  serious  tissue 
changes  in  consequence  of  the  strangulation.  If  this  compara- 
tively harmless  procedure  fails  in  accomplishing  the  desired  object, 
laparotomy  should  be  performed  at  once,  as  every  hour  of  delay 
increases  the  danger  and  diminishes  the  prospect  of  a  favorable 
issue  by  operative  interference.  Statistics  show  a  fearful  mor- 
tality of  operations  done  for  the  relief  of  obstruction  from  vol- 
vulus simply  because  they  were  performed  too  late.  Oettingen 
has  collected  five  cases  of  volvulus  treated  by  the  formation 
of  an  artificial  anus  with  the  result  that  all  the  patients  died.  Of 
the  cases  treated  by  laparotomy,  six  recovered  and  thirteen  died. 
The  cause  of  death  in  these  cases  was  generally  due,  not  to  the 
operation,  but  to  pathologic  changes  in  the  bowel  caused  by  deferring 
surgical  interference  too  long.  Laparotomy,  undertaken  early  in 
the  treatment  of  this  form  of  intestinal  obstruction,  will  show  better 
results  in  the  future.  If  reposition  of  the  twisted  bowel  is  accom- 
plished by  direct  measures  at  a  time  when  the  general  tympanites  is 
not  excessive  and  the  twisted  loop  has  not  undergone  irreparable 
tissue  changes,  the  prospects  of  a  speedy  recovery  are  as  good  as 
after  any  other  intra-abdominal  operation.  Early  diagnosis  and 
early  treatment  by  laparotomy  are  the  requirements  that  will  insure 
success  in  the  treatment  of  volvulus. 

Of  the  operative  treatment  Treves  says  that  simple  laparotomy 
is  an  unpromising  procedure,  but  that  in  future  he  will  make  the 
incision  in  the  median  line,  puncture  the  bowel,  and  attempt  its  re- 
duction ;  if  this  fails  or  the  result  appears  unsatisfactory,  he  will 
evacuate  the  involved  bowel  through  an  opening  in  the  summit  of 


REPOSITION    OF    VOLVULUS,  859 

the  flexure,  unfold  the  volvukis,  and  establish  an  artificial  anus,  using 
the  opening  first  mentioned  for  that  purpose.  The  advice  here  given 
I  should  like  to  modify  by  the  following  suggestions  :  (i)  Never  to 
puncture  the  bowel.  (2)  Substitute  intestinal  anastomosis  for  the 
formation  of  an  artificial  anus.  (3)  Evacuate  not  only  the  twisted 
loop,  but  also  the  bowel  for  some  distance  on  the  proximal  side. 
The  strictest  antiseptic  precautions  are  urgently  indicated  in  the 
surgical  treatment  of  volvulus,  more  particularly  if  the  operation  is 
performed  before  gangrene  or  perforation  has  occurred,  as  in  such 
cases  the  surgeon  has  to  deal,  in  the  majority  of  cases,  with  an  aseptic 
peritoneal  cavity.  The  stomach  and  intestine  below  the  scat  of 
obstruction  should  be  thorough!}'  evacuated  before  the  anesthetic  is 
administered. 

Incision. — A  median  incision  should  always  be  preferred,  ex^en 
if  it  has  been  determined  beforehand  that  the  volvulus  is  located  at 
the  sigmoid  flexure.  The  first  incision  is  made  sufficiently  long  to 
permit  the  introduction  of  the  hand,  for  the  purpose  of  making  a 
brief  manual  exploration  of  the  abdominal  cavity,  with  a  view  to 
determining  the  existence  and  exact  location  of  the  volvulus.  If 
the  cecum  is  found  distended,  it  is  positive  proof  that  the  volvulus 
is  located  at  the  sigmoid  flexure.  A  brief  examination  of  the  sig- 
moid region,  if  the  volvulus  is  located  here,  will  show  that  the 
bowel  compo.sing  the  volvulus  is  more  distended  than  the  remaining 
portion  of  the  colon,  and  the  twi.st  in  the  mesenteiy  can  usually  be 
felt  and  recognized  without  any  difficulty.  In  cases  of  volvulus 
above  the  ileocecal  region  the  colon  will,  of  course,  be  found  col- 
lapsed and  empty. 

If  the  probable  diagno.sis  of  volvulus  has  been  confirmed  by  this 
manual  exploration,  or  if,  after  the  examination  of  the  most  impor- 
tant landmarks  in  determining  the  location  of  the  obstruction,  no 
positive  conclusions  can  be  reached,  no  time  should  be  lost  in 
enlarging  the  incision  sufficiently  to  permit  of  ready  evi.sceration.  As 
the  intestines  are  usually  found  greatly  di.stended,  it  is  of  the  great- 
est importance  to  support  them  well  and  to  keep  them  covered  with 
mf^ist  warm  aseptic  compresses  (saline  solution),  so  as  to  prevent 
injury,  especially  at  the  points  where  they  come  in  contact  with  the 
sharp  margins  of  the  abdominal  inci.sion.  The  twi.sted  portion  of 
the  bowel,  on  account  of  its  greater  degree  of  distention,  will  be 
among  the  first  loops  to  escape,  and  it  is  thus  made  easily  accessible 
to  direct  treatment. 

Reposition  of  Volvulus. — Intra-abdominal  rcpo.sition  of  a  volvu- 
lus is  not  a  feasible  procedure,  hence  the  necessity  of  maUing  a 
large  incision  and  bringing  the  twi.sted  bowel  within  reach  of  sight 
and  direct  manipulation  for  the  purpose  of  dealing  more  efficiently 
and  safely  with  the  displacement.  The  danger  incident  to  i  few 
moments'  exposure  of  the  intestines  is  more  than  counterbalanced 
by  the  risks  that  attend  attempts  at  replacement  through  a  small 
wound  with  the  abdomen  often  distended  to  its  utmr)st  by  dilated 


860  VOLVULUS. 

intestines  with  congested  and  fragile  walls.  Reduction  is  easily- 
accomplished  in  recent  cases  without  adhesions,  and  it  is  not  diffi- 
cult if  the  adhesions  are  of  recent  date.  The  intestinal  loop  is 
rotated  in  an  opposite  direction  from  that  of  the  twist,  until  the 
unfolding  is  completed.  As  a  rule,  the  segment  of  bowel  of  which 
the  volvulus  is  composed  contains  but  little  solid  or  fluid  matter, 
but  is  distended  to  its  utmost  by  gas  that  has  been  generated  within 
it  by  putrefactive  or  fermentative  changes  since  the  accident  occurred. 
If  there  is  any  difficulty  encountered  in  the  unfolding  of  the  dis- 
tended loop,  it  is  advisable  to  empty  the  bowel  on  the  convex  side 
by  a  transverse  incision,  at  least  an  inch  in  length,  as  through  such 
incision  not  only  the  twisted  portion,  but  the  intestine  above  the 
seat  of  obstruction,  can  also  be  emptied  of  its  contents — a  matter  of 
great  importance  in  such  cases.  After  the  bowel  has  been  washed 
out  with  a  warm  solution  of  salicylated  water  or  saline  solution 
further  escape  of  intestinal  contents  is  prevented  by  an  assistant 
compressing  the  wound  during  the  time  the  surgeon  is  engaged  in 
correcting  the  twist.  It  is  absolutely  necessary  to  incise  the  bowel 
in  every  instance  where  the  abdomen  is  opened  for  the  purpose  of 
reducing  a  volvulus.  Before  the  incision  is  made  it  may  be  neces- 
sary to  place  the  patient  on  his  side,  to  enable  the  operator  to  draw 
the  bowel  beyond  the  rest  of  the  intestinal  coils,  so  that,  after  the 
incision  has  been  made,  the  intestinal  contents  can  escape  into  a 
receptacle  without  coming  in  contact  with  the  prolapsed  intestines. 
This  position  is  to  be  maintained  until  the  intestinal  contents  that 
have  accumulated  about  the  seat  of  obstruction  can  be  poured  out 
through  the  incision.  This  pouring-out  process  is  accomplished  by 
seizing  the  highest  loop  that  it  is  deemed  necessary  to  evacuate, 
and,  by  raising  it,  pouring  the  contents  by  the  force  of  gravitation 
from  loop  to  loop  until  the  incision  is  reached.  It  is  an  excellent 
plan  not  only  to  evacuate  as  much  as  possible  of  the  intestinal  con- 
tents, but  also  to  resort  to  irrigation  of  the  bowel  through  the 
incision  with  a  saHne  solution.  Such  thorough  evacuation  of  the 
bowel  at  and  above  the  seat  of  obstruction  accompHshes  three 
desirable  objects  :  (i)  It  facilitates  the  replacement  of  the  intestines 
into  the  abdominal  cavity.  (2)  It  directly  unloads  the  distended 
paretic  intestine,  and  thus  favors  the  return  of  peristaltic  action. 
(3)  It  exerts  a  potent  influence  in  preventing  putrefactive  and  fer- 
mentative changes  in  the  intestines  after  the  operation.  Before  the 
bowel  is  returned  the  incision  is  closed  in  the  usual  manner  by 
Czerny-Lembert  sutures.  If  one  or  more  circumscribed  points  of 
gangrene  are  found,  they  should  be  buried  by  suturing  over  them 
healthy  peritoneum.  The  bowel  is  then  returned,  with  a  fair  expec- 
tation that  after  removal  of  the  strangulation  the  gangrene  will  not 
extend.  If  large  portions  of  the  intestines  or  the  entire  loop  show 
evidences  of  gangrene,  enterectomy  has  become  an  unavoidable 
evil.  If,  as  is  usually  the  case  in  such  instances,  the  patient  is  in  a 
collapsed  condition,  no  time  should  be  lost  in  the  restoration  of  the 


INTESTINAL    ANASTOMOSIS.  86 1 

continuity  of  the  intestinal  canal  by  circular  enterorrhaphy,  as  the 
same  object  is  attained  in  a  much  shorter  time  by  closing  both  ends 
of  the  intestine  and  making  a  lateral  anastomosis. 

Intestinal  Anastomosis. — Cases  may  occur  where  it  will  be  found 
impossible  to  unfold  the  volvulus  without  tearing  the  bowel,  and 
the  question  arises,  Is  it  best  to  resect  and  suture  the  ends  of  the 
intestine,  or  to  leave  the  volvulus  and  establish  a  communication 
between  the  intestine  above  and  below  the  obstruction  ?  Mr. 
Hutchinson  {op.  cit.)  reports  such  a  case.  A  soldier,  aged  forty- 
six,  in  good  health,  who  was  in  bed  in  the  hospital  after  removal 
of  a  fatty  tumor,  two  da}'s  after  operation  complained  of  pain  in 
the  back  and  abdomen.  He  had  not  left  the  bed  since  the  opera- 
tion. The  following  day  the  pain  was  less;  slightly  nauseated; 
constipation;  injections  and  laxatives  produced  no  effect,  excepting 
to  increase  the  sickness.  On  the  fifth  day  after  the  attack  the 
retching  and  vomiting  were  persistent  and  distressing.  On  the 
seventh  day  the  abdomen  was  distended  and  coils  were  visible.  The 
S}-mptoms  became  more  and  more  threatening,  until  death  occurred 
on  the  tenth  day  after  the  commencement  of  the  attack. 

^'Autopsy. — Three  inches  above  the  ileocecal  valve  a  coil  of  small  intestine  was 
found  twice  twisted  round  a  portion  of  the  mesentery,  and  the  canal  of  the  bowel  was 
thus  completely  obstructed.  There  were  no  recent  iuflammatoiy  changes  about  this  part 
of  the  intestine,  but  from  the  dense  and  contracted  condition  of  the  bowel  where  twisted, 
it  must  have  been  for  some  time  narrowed  at  this  point.  When  I  moved  aside  the  coils 
of  intestine  which  lay  in  front  of  the  obstruction, — more  or  less  adherent  amongst  them- 
selves by  means  of  old  and  tough  peritoneal  bands, — and  when  I  endeavored  to,  and 
after  some  sorting  of  the  parts  succeeded  in  unrolling  the  twisted  canal,  I  'was  glad  not 
to  have  attetiipted  the  operation  durifig  the  life  of  the  patient,  for  it  'would  have  been  im- 
possible.     [Italics  my  own.] 

^'Criticism. — It  seems  not  improbable  that  in  this  case  some  old  adhesions  favored 
the  formation  of  the  twist.  It  may  be  alleged  that  an  early  operation  would  have  found 
the  unravelment  not  so  difficult ;  but  then  it  must  be  remembered  that  the  early  symptoms 
were  but  slightly  marked.  The  case  was  not  considered  a  serious  one  until  seven  days 
had  passed.  It  is  in  order  to  illustrate  the  vagueness  of  the  early  symptoms  that  I  have 
quoted  this  case." 

It  is  difficult  to  apj)reciate  the  reasons  for  self-congratulation  on 
the  part  of  Mr.  Hutchinson  for  not  having  made  an  attempt  to  save 
the  life  of  this  patient  by  surgical  interference.  The  result  might 
have  been  better,  and  certainly  could  not  have  been  any  worse. 
The  time  will  come,  and  is  not  far  distant,  when  as  much  blame 
will  be  attached  to  a  surgeon  who  will  look  on  as  an  idle  spectator 
at  the  bed.side  of  a  patient  whose  life  is  in  danger  from  intestinal 
obstruction  as  now  falls  upon  an  obstetrician  who  permits  a  partu- 
rient woman  to  die  imdelivercd.  l^tit  supposing  that  unravelment 
would  have  been  found  impossible  or  impracticable,  two  jjlaiis  of 
treatment  were  still  left  for  the  operator  to  pursue,  and  either  of 
them  might  pcssibly  have  become  a  life-saving  measure.  As  the 
bowel  presented  no  evidences  of  gangrene,  resection  was  not  to  be 
thought  of,  but  the  contiiniity  f>f  the  intestinal  canal  might  have 
been  restored  by  intestinal  ana.stomosis  with  permanent  exclu.sion 
of  the  volvulus  from  the  fecal  circulation.      Ov,  if  the  operator  had 


862  VOLVULUS, 

no  faith  in  this  procedure,  he  could  at  least  have  made  an  artificial 
anus  above  the  seat  of  obstruction.  An  intestinal  anastomosis 
between  the  intestine  above  and  below  the  volvulus  by  means  of 
decalcified  perforated  bone  discs  or  a  Murphy  button  can  be  done 
in  a  few  minutes,  and  at  once  restores  the  continuity  of  the  intes- 
tinal canal.  If  such  a  procedure  is  chosen  in  the  treatment  of  an 
irreducible  volvulus,  it  becomes  necessary  to  make  provision  for  a 
permanent  outlet  of  the  contents  of  the  isolated  segment  of  the 
intestine  that  constitutes  the  volvulus,  as  the  obstruction  of  both 
ends  of  this  portion  may  prove  to  be  permanent.  This  can  be 
accomplished  by  making  a  second  anastomosis  between  the  apex 
of  the  volvulus  and  an  adjoining  intestinal  loop,  in  preference  to  a 
loop  below  the  seat  of  obstruction.  Such  a  procedure  will  estab- 
lish, with  but  little  additional  risk,  a  permanent  fistulous  opening 
between  the  twisted  portion  of  the  bowel  and  the  fecal  circulation, 


Fig-  5^^- — '^)  Showing  long  mesentery  of  sigmoid  flexure;  i,  shortening  of  mesentery- 
after  reduction  of  a  volvulus  by  duplication  and  suturing. 

and  will  prevent  any  danger  that  might  arise  from  overdistention 
and  perforation  should  the  obstruction  caused  by  the  volvulus 
remain  permanent.  In  making  intestinal  anastomosis  the  lateral 
apposition  should  be  preceded  by  thorough  evacuation  and  disinfec- 
tion of  the  intestine.  In  order  to  hasten  plastic  adhesions  the 
serous  surfaces  that  are  to  be  coaptated  should  be  freely  scarified. 
Shortening  of  Mesentery. — After  the  reduction  of  a  volvulus  has 
been  accomplished  by  operative  measures  it  is  desirable  to  protect 
the  patient  in  the  future  against  a  possible  recurrence  of  the  same 
accident  in  the  same  place.  As  an  elongated  mesentery  plays  the 
most  important  role  in  the  production  of  volvulus,  this  can  be  done 
in  a  few  moments  with  certainty  and  safety  by  shortening  the  mes- 
entery. Resection  of  the  mesentery  is  out  of  the  question,  as  such 
a  procedure  would  in  all  probability  result  in  gangrene  of  a  corre- 


OPERATION. 


863 

spending  portion  of  the  intestine.  Shortening  of  the  mesentery 
however,  can  be  effected  by  folding  the  mesenterx'  upon  itself  in  a 
direction  parallel  to  the  bowel,  and  suturing  the'  apex  of  the  fold 
to  the  root  of  the  mesentery.  By  this  method  the  floating  bowel 
is  firmly  anchored,  and  a  recurrence  of  the  volvulus  is  made  im- 
possible. The  indications  for  flushing  the  abdominal  cavity  and  for 
establishing  drainage  are  the  same  as  in  laparotomy  for  other  forms 
oi  intestinal  obstruction.  I  have  successfully  resorted  to  this 
method  of  preventing  a  relapse  in  two  cases,  and  as  an  illustration 
of  the  procedure  will  insert  here  a  brief  history  of  the  first  one. 

The  patient  was  a  man,  sixty-three  years  of  age,  a  carpenter  by  occupation.  He  had 
never  suffered  from  any  bowel  complaint  except  occasional  attacks  of  constipation  that 
always  yielded  to  mild  laxatives.  (Jn  the  morning  of  October  6th,  while  walking  around 
in  his  room,  he  was  suddenly  seized  with  a  severe  pain  in  the  middle  and  lower  part  of 
the  abdomen.  He  sought  rest  in  the  recumbent  position  and  the  pain  gradually  subsided 
At  this  time  the  appetite  was  impaired,  but  there  was  no  nausea  or  vomitincr'  Toward 
evening  he  felt  somewhat  distressed  in  the  abdomen,  a  circumstance  which  he  attributed 
to  flatulency-,  as  he  felt  relieved  after  loosening  his  clothing.  The  following  morning  he 
awoke  tree  from  pain,  but  on  rising  the  pain  returned.  He  remained  quiet  all  day  and 
suffered  only  an  occasional  attack  of  colicky  pain.  He  rested  well  during  the  night  and 
on  the  third  morning  he  was  again  free  from  pain.  He  ate  a  light  breakfast  and  started 
to  resume  work  at  his  shop.  On  his  way,  however,  the  pain  returned.  On  reaching  his 
destination  the  severity  of  the  pain  increased  and  he  returned  home.  The  pain  yielded 
to  rest,  but  the  abdomen  became  more  distended.     The  fourth  day  he  was  again  able  to 

f  I  >  ^u  !  ^"'■''^^^  ^^"^  "°'  "'"''^^  ^*""  ^^'^  beginning  of  the  attack,  he  took  a  dose 
ot  rhubarb  in  the  evening.  As  the  cathartic  did  not  act  by  the  following  morning  he  took 
an  enema,  which  brought  away  a  small  quantity  of  fecal  matter.  The  following  two 
days  the  pain  became  severer  and  the  distention  of  the  abdomen  greater  ■  there  was 
nausea  but  no  vomiting.  He  did  not  consider  himself  sufficiently  ill  to  call  a  physician 
until  October  12th.  The  physician  diagnosticated  some  form  of  intestinal  obstruction 
and  sent  tlie  patient  to  the  hospital  to  be  placed  under  surgical  treatment.  Examination 
at  this  time  showed  that  the  temperature  was  normal ;  pulse  90,  soft,  and  compressible  • 
copious  eructations,  but  little  nausea  and  no  vomiting.  According  to  his  statement  he 
had  not  had  a  proper  movement  of  his  bowels  since  the  attack,  and  no  flatus  passed  per 
rectum.  Abdomen  enormously  distended  and  tympanitic  over  the  entire  surface  ;  contour 
of  intestinal  coils  visible  at  a  number  of  places.  It  was  evident  that  the  obstruction  was 
located  low  down  in  the  colon,  probably  in  tlie  sigmoid  flexure,  and  it  was  sumiised,  from 
the  history  of  the  case  and  the  symptoms  presented,  that  it  was  caused  by  either  a  volvulus 
or  a  circular  carcinoma.  Laparotomy  was  advised,  and  as  the  i)atient'at  once  gave  his 
consent,  it  was  performed  the  following  day,  October  13th,  about  noon.  After  he  came 
into  the  hospital  the  nurse  administered  two  ounces  of  castor  oil  in  one  dose  without  any 
appreciable  effect  being  produced. 

Opei-alivn.—h^  the  patient  was  suffering  at  the  same  time  from  a  chronic  bronchial 
catarrh,  chloroform  was  used  in  place  of  ether  as  an  anesthetic.  The  temiK-ralure  of  the 
room  was  kept  at  85'^  to  90°  Y .  The  most  careful  aseptic  ])iei)aiations  were  made,  and 
dunng  the  operation  rigid  aseptic  measures  were  carried  out.  The  abdomen  was  opened 
by  a  median  incision  half-way  between  the  umbilicus  and  pubcs,  and  sufficiently  large  to 
permit  introduction  of  the  hand.  Intra-abdominal  manual  exi)loralion  showed,  in  the 
first  place,  that  the  cecum  was  greatly  distended  ;  conse(|uently  the  examination  was  con- 
tinued by  exploring  the  sigmoid  region.  Kelow  the  sigmoid  flexure  the  colon  and  upper 
{xjrtion  of  the  rectum  were  found  completely  empty  and  colla|)sed.  The  sigmoid  flexure 
could  be  distinclly  felt,  and  was  enormously  distended  and  twisted  around  its  mesenteric 
axis.  The  twist  in  the  mesentery  could  be  distinclly  fell.  No  time  was  lost  in  useless 
attempts  to  effect  reduction.  The  incision  was  enlarged  in  an  ujnvard  <liir<  lion  to  three 
inches  abf>ve  the  umbilicus.  As  the  intestines  escaped,  they  were  covered  wilh  hot, 
moist  aseptic  compresses  and  carefully  supported  by  two  .issislants.  The  small  intesline 
was  greatly  distended  and  extremely  vascular  ;  the  visceral  perilonium  had  lost  its  glis- 
tening appearance.  The  colon  had  become  .so  much  distended  and  elongated  that  the 
transverse  [x>rtion,  in  the  shape  of  a  horseshoe,  was  found  displaced  in  a  downwanl  direc- 
tion to  near  the  piibes  The  sigmoid  flexure  was  twisted  around  its  tnesi-nteric  axis  in 
one  complete  twist.      The  twisted  portion  of  the  mesentery  was  the  seat  of  a  limited  j)lastic 


864  VOLVULUS. 

peritonitis  that  had  resulted  in  adhesions.  The  part  of  the  bowel  constituting  the  vol- 
vulus measured  at  least  eighteen  inches  in  circumference,  and  its  walls  appeared  to  be  of 
the  thinness  of  parchment  paper.  Reposition  was  very  easily  effected  by  simply  turning 
the  bowel  in  an  opposite  direction  to  that  of  the  twist  until  the  normal  position  was  restored. 
Peristaltic  action  appeared  to  be  almost  completely  suspended,  both  in  the  large  and  the 
small  intestine.  It  would  have  been  mechanically  almost  impossible  to  return  the  intes- 
tines into  the  abdominal  cavity  without  producing  serious  injury,  perhaps  complete  rupture, 
of  the  bowel ;  hence  an  incision  an  inch  in  length  was  made  into  the  colon,  where  the 
distention  was  the  greatest.  The  incision  was  made  parallel  to  the  long  axis  of  the  bowel, 
and  directly  opposite  its  mesenteric  attachment.  The  part  of  the  bowel  that  had  been 
twisted  contained,  besides  gas,  only  a  very  small  amount  of  fluid  fecal  matter.  The  inci- 
sion did  not  empty  more  than  this  part  of  the  bowel.  As  a  large  amount  of  fluid  feces 
had  accumulated  above  the  seat  of  obstruction,  this  was  evacuated  by  the  "pouring-out 
process"  previously  described,  and  in  this  manner  almost  the  entire  colon  was  emptied. 
The  incised  portion  of  the  bowel  was  drawn  well  forward,  and  held  in  this  position  by  an 
assistant  during  the  entire  time  required  for  unloading  the  bowel,  and  thus  soiling  of  the 
intestines  and  abdominal  cavity  was  prevented.  As  far  as  it  could  be  readily  done  the 
intestine  was  subsequently  washed  out  with  warm  salicylated  water.  The  wound  was 
closed  with  two  rows  of  silk  sutures.  The  mesentery  of  the  volvulus  was  at  least  eight 
inches  in  length,  and  was  shortened  more  than  one-half  by  the  method  previously  described. 
Replacement  of  the  intestines  was  now  accomplished  without  any  difficulty,  and,  after 
drying  the  peritoneal  cavity  with  sponges  wrung  out  of  warm  sterilized  water,  the  external 
incision  was  closed  in  the  usual  manner.  No  drainage.  The  customary  antiseptic  com- 
press, composed  of  iodoform  gauze  and  salicylated  cotton,  was  applied,  and  the  abdom- 
inal walls  were  well  supported  with  adhesive  strips.  Outside  of  the  adhesive  strips  a 
layer  of  common  cotton  was  applied,  and  over  this  a  snugly  fitting  binder.  Duration  of 
operation  nearly  an  hour  and  a  half.  The  patient  recovered  rapidly  from  the  immediate 
effects  of  the  operation.  At  8  o'clock  in  the  evening  temperature  was  100.5°  F.,  pulse 
1 10.  Free  movement  of  bowels  ;  feces  liquid,  dark  colored,  and  of  a  very  offensive  odor. 
Complained  of  no  pain,  but  a  sensation  of  soreness  in  the  abdomen. 

October  J4th. — Temperature  99.5°  F.,  pulse  90.  During  the  night  had  four  fluid 
passages  of  the  same  offensive  character.  So  far  the  patient  had  not  been  allowed  any 
food  by  the  mouth.  Thirst  was  relieved  by  giving  water  in  small  quantities  and  frequently 
repeated.  In  the  evening  the  patient  felt  so  well  that  during  a  brief  absence  of  the  nurse 
he  got  out  of  bed  and  walked  around  the  room. 

October  i^th. — Temperature  and  pulse  normal.  Imprudence  on  part  of  patient  did 
not  seem  to  have  resulted  in  any  harm.  From  this  time  on  the  patient  was  allowed  liquid 
food,  and  after  the  lapse  of  another  week  was  placed  on  the  ordinary  hospital  diet.  With 
the  exception  of  a  small  parietal  abscess  the  recovery  was  not  marked  by  any  untoward 
symptoms.      The  patient  left  the  hospital  three  weeks  after  the  operation  in  perfect  health. 

So  far  as  I  am  aware  no  recurrence  has  taken  place  in  either  of 
the  cases  of  mesenteric  dupHcation  after  volvulus  reduction. 

Vejitrojixation  is  the  usual  procedure  resorted  to  by  surgeons 
for  the  purpose  of  guarding  against  a  recurrence.  It  may  be  urged 
against  this  practice  that  the  parietal  adhesions  often  give  way,  and 
in  other  instances  are  drawn  out  gradually  into  long  cords  that  may 
become  another  cause  of  mechanical  obstruction  besides  the  partially 
hberated  loop,  which  again  may  become  twisted. 

Enterostomy  is  always  contraindicated  in  the  treatment  of  volvu- 
lus, as  all  the  cases  thus  treated  collected  by  H.  Braun,  eight  in 
number,  died.  Enterostomy  or  colostomy  may  become  a  useful 
procedure  after  reduction  or  resection  of  the  volvulus  by  laparotomy 
when  the  intestine  on  the  proximal  side  is  much  distended  and 
paretic.  Lennander  reports  two  cases  of  this  kind  treated  by  lapa- 
rotomy, reposition,  and  typhlostomy,  and  suggests  that  in  all  cases 
of  obstruction  of  the  large  intestine  an  artificial  anus  should  be  es- 
tabhshed  in  the  cecum  if  it  become  evident,  after  washing  with  a 
physiologic  salt  solution,  that  the  intestine  does  not  possess  a  nor- 


ENTERECTOMY.  35,- 

mal  power  of  contraction.  Even  in  resection  witii  immediate  sutur- 
ing of  the  mtestine,  as  in  cancer,  the  surgeon  should  be  prepared  to 
estabhsh  an  anus  m  the  cecum  if,  owing  to  the  degree  of  strancrula- 
tion,  the  portion  of  the  intestine  beyond  has  not  been  thoroughly 
emptied.  The  example  of  James  Israel  may  be  followed  in  some 
cases  with  advantage  in  regard  to  the  necessity  of  establishincr  an 
artificial  outlet  from  the  part  of  the  intestine  constituting  the  volvu- 
lus. In  a  case  of  volvulus  of  the  sigmoid  flexure  he  found  the  tym- 
panites limited  to  the  sigmoid  at  the  time  laparotomy  was  made 
and,  being  fearful  that  the  peristaltic  action  would  not  be  restored' 
he  sutured  the  center  of  the  paretic  portion  of  the  bowel  into  the 
abdominal  wound  ;  as  the  next  day  the  symptoms  of  obstruction 
increased,  he  incised  the  bowel.  For  a  short  time  the  feces  escaped 
through  the  artificial  anus  ;  later,  per  vias  naturales,  after  which  the 
artificial  anus  closed  spontaneou.sly.  He  believes  that  this  method 
of  dealing  with  the  paretic  bowel  also  prevents  recurrence  of  the 
volvulus. 

Enterectomy  is  indicated  in  all  cases  in  which  the  volvulus  ex- 
hibits indications  of  gangrene.  Very  few  successful  cases  of  enter- 
ectomy for  volvulus  have  so  far  been  reported.  Braun  reports  a 
successful  resection  of  a  volvulus  of  the  sigmoid  flexure  with  the 
formation  of  an  artificial  anus. 

Schlange  resected  successfully  135  cm.  of  the  ileum  for  gan- 
grene the  result  of  volvulus.  The  intestine  showed  unmistakable 
signs  of  incipient  gangrene,  and  the  mesenteric  veins  corresponding 
with  the  section  of  the  intestine  removed  were  all  thrombosed. 
The  resected  ends  were  united  by  circular  suturing  and  the  bowel 
returned.  The  wound  was  tamponed  with  iodoform  gauze  that 
embraced  the  line  of  suturing.  The  tampon  was  removed  on  the 
third  day,  when  the  wound  was  lightly  packed  with  a  strip  of  iodo- 
form gauze  for  seven  days  longer,  it  then  being  closed  by  secondary 
suturing.  The  recovery  was  rapid,  and  several  weeks  after  the 
operation  the  patient  pre.sented  all  the  appearances  of  perfect  health 
and  unimpaired  nutrition. 

F^nterectomy  for  a  gangrenous  volvulus  is  one  of  the  most  seri- 
ous of  all  abdominal  operations,  and  any  surgeon  who  is  so  fortunate 
as  to  .save  a  life  by  this  operation  deserves  the  highest  credit.  The 
patients  suffering  from  this  stage  of  volvulus  are  always  in  a  critical 
general  condition  and  exposed  to  many  sources  of  infection.  If  the 
patient  is  much  collap.sed,  or  becomes  .so  during  the  operation,  the 
formation  of  an  artificial  anus  becomes  necessary  to  .save  time.  If  it 
can  be  done,  the  two  ends  of  the  bowel  should  be  .sewed  together 
on  the  me.senteric  side,  and  fixed  together  by  suturing  in  the  abdom- 
inal inci.sion.  In  the  event  of  recovery,  the  continuity  of  the  intes- 
tinal canal  can  be  later  restored  with  little  risk  to  life.  If  circular 
suturing  after  resection,  in  cases  that  warrant  the  attempt,  can  not 
be  done,  anastomosis  in  some  form  comes  to  our  aid  and  disj)en.ses 
with  the  nece.s.sity  of  establishing  a  permanent  artificial  anus.  It  is 
55 


^66  FLEXION    AND    ADHESIONS. 

in  such  cases,  too,  that  the  suggestion  made  many  years  ago  by  me 
might  find  a  useful  application.  This  suggestion  was  to  the  effect 
of  implanting  a  section  of  the  small  intestine  to  fill  in  the  gap  between 
the  two  bowel  ends,  an  operation  that  would  necessitate  the  making 
of  three  circular  enterorrhaphies.  The  suggestion  has  also  been 
made,  to  meet  a  similar  contingency  after  resection  of  the  sigmoid 
flexure,  to  close  the  proximal  end  by  invagination  and  sutures,  and 
implant  the  rectal  end  into  a  slit  in  the  lower  portion  of  the  ileum, 
thus  excluding  the  remaining  portion  of  the  colon  from  the  fecal 
circulation. 

C.  Bayer  proposes,  in  similar  cases,  to  implant  into  the  defect  a 
loop  of  the  lower  portion  of  the  ileum,  establish  a  communication 
between  both  ends  by  anastomosis,  and,  finally,  unite  the  two  limbs 
of  the  loop  by  a  third  anastomotic  opening,  an  operation  that, 
under  favorable  circumstances,  appears  rational  and  justifiable. 


CHAPTER  XXV. 


ANATOMICOPATHOLOGIC  FORMS  OF  INTESTINAL 
OBSTRUCTION   (Continued), 

Flexion  and  adhesions  are  occasionally  met  with  as  the  sole 
cause  of  mechanical  obstruction,  and  the  former  is  usually  the 
remote  consequence  of  the  latter.  Flexion  gives  rise  to  intestinal 
obstruction  by  the  formation  of  a  spur  on  the  mesenteric  side, 
which,  when  sufficiently  well  developed  to  encroach  upon  the 
lumen  of  the  bowel,  usually  intercepts  the  fecal  current  by  its 
mechanical  action. 

Adhesions  without  distortion  of  the  bowel  may  cause  intestinal 
obstruction  by  suspending  peristalsis  by  mural  fixation. 

FLEXION. 

As  many  instances  are  on  record  where  flexion  of  the  bowel 
constituted  the  cause  of  intestinal  obstruction,  this  condition  was 
artificially  produced  in  animals  either  by  making  a  partial  enterec- 
tomy  by  removing  a  wedge-shaped  piece  from  one  side  of  the  bowel 
or  by  bending  the  bowel  upon  itself  acutely  and  fixing  it  in  this 
position  with  catgut  sutures. 

Experiment  8. — Dog,  weight  sixty  pounds.  A  wedge-shaped  piece  of  the  wall 
of  the  ileum  was  removed  from  the  concave  side,  with  a  corresponding  portion  of  the 
mesenteric  attachment,  and,  after  arresting  the  bleeding  by  tying  several  vessels  with  cat- 
gut, the  wound  was  closed  transversely  by  two  rows  of  sutures.  The  excised  piece 
measured  one  inch  at  its  base,  and  the  apex  reached  as  far  as  the  median  line  of  the  bowel. 
Immediately  after  excision  the  convex  portion  of  the  bowel,  which  had  become  acutely 
flexed  by  uniting  the  wound,  presented  a  livid,  congested  appearance,  and,  after  the 
sutures  had  been  tied,  the  cyanosis  increased.  The  area  of  disturbance  of  the  circulation 
corresponded  to  the  width  of  the  base  of  the  excised  portion.  About  fourteen  inches 
from  this  place  a  similar  piece  was  excised  from  the  convex  side  of  the  bowel,  and  the 


FLEXION.  867 

wound  closed  in  the  same  manner.  At  this  point  the  flexion  was  only  slight,  the  mesen- 
teric portion  forming  the  prominence  of  the  curve.  On  the  third  day  the  temperature 
rose  to  105.6°  F.,  and  on  the  following  day  the  animal  died  with  symptoms  indicative  of 
perforative  peritonitis.  On  opening  the  abdomen  diffuse  general  peritonitis  was  found, 
together  with  numerous  adhesions.  Gangrene  and  perforation  were  found  on  the  convex 
side  directly  opposite  the  tirst  operation.  Second  visceral  wound  closed  and  lumen  of 
bowel  at  this  point  somewhat  contracted,  but  permeable  to  fluids. 

Experiment  9. — Large  adult  cat.  A  triangular  piece  measuring  one  inch  at  its  base 
and  the  apex  reaching  a  little  beyond  the  middle  line  of  the  bowel  was  removed  from 
the  convex  side  of  the  ileum,  and  the  wound  closed  transversely  by  Czerny-Lembert 
sutures.  After  closure  of  the  wound  the  bowel  presented  an  obtuse  angle  at  point  of 
partial  resection,  the  apex  being  formed  by  the  mesenteric  portion.  The  stools  were 
bloody  the  second  day  after  operation.  The  animal  remained  in  excellent  condition  until 
it  was  killed,  forty-three  days  after  operation.  Adhesions  of  loops  of  small  intestine  to 
abdominal  wound  and  of  omentum  and  adjacent  intestines  at  point  of  operation  were 
found.  The  extent  of  flexion  was  found  somewhat  diminished,  yet  the  concavity  on  the 
convex  side  of  the  bowel  was  well  marked.  The  size  of  the  bowel  above  and  below  the 
point  of  operation  was  equal,  showing  that  the  flexion  had  not  acted  as  a  cause  of  obstruc- 
tion. On  opening  the  bowel  a  pouch-like  bulging  was  found  on  the  mesenteric  side, 
which  appeared  to  compensate  for  the  narrowing  caused  by  the  artificial  stenosis.  Two 
of  the  deep  sutures  still  remained  attached  to  the  inner  surface  of  the  bowel. 

Experiment  10. — Large  adult  cat.  In  this  case  a  loop  of  the  middle  portion  of 
the  ileum,  four  inches  in  length,  was  acutely  flexed  in  such  a  manner  that  the  peritoneal 
surfaces  of  the  convex  side  were  brought  in  contact,  and  in  this  position  the  bowel  was 
fixed  by  a  number  of  fine  catgut  sutures.  No  symptoms  pointing  toward  intestinal 
obstruction  were  obser%'ed,  and  the  animal  was  killed  sixteen  days  after  the  operation. 
The  wound  was  found  completely  united,  and  signs  of  peritonitis  were  absent.  The 
angle  of  flexion  had  somewhat  diminished,  but  otherwise  the  bowel  was  adherent  in  posi- 
tion left  after  operation.  The  bowel  presented  no  dilatation  above  nor  contraction  below 
the  flexion,  showing  that  complete  permeability  of  the  canal  at  the  point  of  flexion  was 
quickly  restored. 

The  partial  exci.sion  on  concave  side  of  bowel  in  experiment 
8  illustrates  the  danger  of  suturing  wounds  in  this  locality  where 
the  blood  supply  from  the  mesentery  is  likewise  impaired,  as 
gangrene  of  the  remaining  portion  of  the  bowel  is  almost  certain 
to  take  place.  In  all  wounds  on  this  side  of  the  bowel  more  than 
half  an  inch  in  length  there  is  also  another  great  danger  that  attends 
transverse  suturing — viz.,  stenosis,  which  may  become  the  cause 
of  intestinal  obstruction.  As  tiie  small  intestine  naturally  describes 
quite  a  large  curve,  with  the  concavity  on  the  mesenteric  side, 
closure  of  a  wound  involving  this  portion  of  the  bowel  gives  rise 
to  acute  flexion,  which,  at  least,  during  the  process  of  healing, 
must  cause  more  or  less  ob.struction,  until,  by  j'ielding  of  the 
opposite  portion  of  the  intestinal  wall,  an  adequate  dilatation  of 
the  caliber  of  the  tube  has  taken  place.  A  considerable  portion  of 
the  wall  on  the  convex  side  of  the  bowel  can  be  removed  and 
sutured  transversely  until  the  bowel  has  been  transformed  into  a 
straight  tube,  and  a  wound  an  inch  in  length  will  make  but  a  slight 
flexion,  which  furnishes  no  serious  mechanical  obstacle  to  the 
pas.sage  of  the  intestinal  contents.  In  this  connection  tiie  question 
arises  :  Does  simple  flexion,  even  if  acute,  without  diminution  of 
the  lumen  of  the  bowel,  give  rise  to  symptoms  of  r)bstructioii  ?  I 
have  made  numerous  flexions  when  performing  operations  for 
establishing  intestinal  anastomosis,  and  in  most  instances  .satisfied 
my.self,  by  examination  of  the  .specimens,  that  fluids  pa.s.sed  them 
without  great  difficulty.      If  the  bowel  at  the  j^oint  of  flexion   re- 


868  FLEXION    AND    ADHESIONS. 

main  free,  certain  portions  of  its  wall  will  yield  to  pressure  of  the 
fluid  intestinal  contents,  and  gradually  the  lumen  of  the  bowel  will 
become  restored.  If,  on  the  other  hand,  the  entire  circumference 
of  the  bowel  at  the  point  of  flexion  has  become  fixed  and  immov- 
able by  inflammatory  adhesions  or  other  pathologic  products,  a 
compensating  dilatation  becomes  impossible,  and  the  flexion  be- 
comes a  direct  and  serious  cause  of  obstruction. 

Every  pathologist  who  has  carefully  examined  the  intestinal 
canal  of  persons  who  have  succumbed  to  acute  peritonitis  must 
have  noticed  the  presence  of  numerous  flexions  caused  by  visceral 
and  parietal  adhesions,  and  yet  such  patients  seldom  exhibited 
well-marked  symptoms  of  intestinal  obstruction  during  life.  I  have 
observed  the  same  conditions  in  animals  during  my  experimental 
work  on  the  intestinal  canal,  and  seldom  found  that  simple  flexion 
gave  rise  to  intestinal  obstruction.  In  recent  cases  of  flexion,  of  course, 
the  circumference  of  the  lumen  of  the  bowel  at  the  point  of  flexion  is 
equal  in  size  to  that  above  or  below  the  obstruction.  The  obstruction 
in  such  cases  is  not  caused  by  stenosis,  but  by  compression  of  the 
distal  limb  of  the  flexion  by  the  intestinal  contents  in  the  proximal 
portion,  thus  causing  a  valvular  closure  not  at,  but  just  beyond,  the 
seat  of  flexion.  This  is  more  likely  to  take  place  if  the  apex  of  the 
flexed  portion  of  the  bowel  is  adherent  at  some  fixed  point,  as  in 
this  case  compensatory  dilatation  of  the  intestinal  wall  at  a  point 
corresponding  to  the  apex  of  the  flexion  can  not  take  place.  When 
a  flexion  has  existed  for  a  long  time  without  having  given  rise  to 
symptoms  of  obstruction,  it  finally  may  cause  occlusion  by  a  cica- 
tricial stenosis  at  the  seat  of  flexion,  due  to  a  circumscribed  plastic 
inflammation  and  cicatricial  contraction  of  the  inflammatory  prod- 
uct. Such  a  case  came  under  the  observation  of  Obalinski.  A 
boy,  eighteen  years  old,  had  suffered  from  typhoid  fever  eight 
months  before  the  attack  of  intestinal  obstruction  set  in.  Some 
time  before  the  acute  symptoms  appeared  he  suffered  from  pain  in 
the  abdomen,  which  gradually  increased  in  intensity  until  the  clini- 
cal picture  of  obstruction  was  well  marked.  On  the  eighth  day 
after  the  attack  the  abdomen  was  opened  by  a  median  incision. 
Distended  and  collapsed  intestinal  coils  came  within  easy  reach. 
The  obstruction  consisted  of  a  rectangular  flexion  of  the  small 
intestine  caused  by  a  pseudoligament  the  size  of  a  lead-pencil. 
After  division  of  this  band  and  straightening  the  bowel,  it  was  seen 
that  the  bowel  was  considerably  contracted  at  the  point  of  flexion 
by  a  circular  cicatrix,  but  as  it  was  permeable,  nothing  further  was 
done.  The  boy  was  discharged  cured  four  weeks  after  the  opera- 
tion. That  the  pressure  of  intestinal  contents  in  the  proximal  bar 
is  exerted  mainly  upon  the  spur  that  forms  in  acute  flexions  be- 
tween the  two  bars  is  well  shown  by  a  specimen  described  by 
Birkett,  where  an  intestinal  anastomosis  was  established  spontane- 
ously by  ulceration  between  the  approximated  adherent  tubes  at 
the   point  of  compression,  so   that   the  intestinal   contents   passed 


FLEXION. 


869 


directly  from  one  intestine  to  the  other  through  this  "fistula  bimu- 
cosa  "  instead  of  traversing  the  loop.  The  patient  was  a  man,  aged 
fift\--eight,  who,  six  months  before  his  death,  had  presented  a 
strangulated  hernia  that  had  been  reduced  by  taxis.  When  the 
flexion  is  very  acute,  the  spur  formed  by  the  apex  of  the  approxi- 
mated walls  of  both  bars  acts  like  a  valve  in  closing  the  lumen  of 
the  distal  bar  under  the  influence  of  the  hydrostatic  pressure  from 
the  accumulation  of  intestinal  contents  above  the  seat  of  flexion. 
Nicaise  has  reported  a  typical  case  of  this  kind.  A  man,  aged 
twenty-five  years,  was  operated  upon  for  strangulated  hernia  five 
years  before  the  attack  of  intestinal  obstruction.  Since  the  herni- 
otomy he  had  suffered  frequently  from  attacks  of  vomiting  and  con- 
stipation with  abdominal  pain.  The  last  attack  was  so  severe  that 
enterotomy  was  performed.  He  died  the  next  day.  The  necropsy 
revealed  an  acute  flexion  that  had  become  permanent  by  old  adhe- 
sions. The  flexion  was  so  acute  that  the  mucous  membrane  at  its 
apex  constituted  a  kind  of  valve  across  the  lumen  of  the  bowel. 
After  liberation  of  a  flexed  bowel  the  seat  of  an  intestinal  obstruc- 
tion, it  becomes  a  step  in  the  operation  to  resort  to  such  prophy- 
lactic measures  as  may  appear  necessary  to  prevent  a  return  of  the 
malposition,  and  to  cover,  as  far  as  possible,  the  peritoneal  defects 
that  have  been  made  during  the  separation  of  the  loop.  Winslow 
reports  a  case  in  point.  In  this  case  a  loop  of  the  small  intestine 
was  found  firmly  adherent  in  the  pelvis  over  an  area  of  six  inches, 
and  sharply  flexed.  After  it  was  carefully  detached  it  was  found 
denuded  of  peritoneum  over  a  small  space.  The  continuity  of  the 
peritoneal  surface  was  restored  by  applying  a  number  of  sutures 
transversely  to  the  long  axis  of  the  bowel.  It  is  distinctly  stated 
that  this  portion  of  the  bowel  was  deeply  congested,  hence  the 
seat  of  the  textural  changes  consequent  upon  the  obstruction.  In 
most  ca.ses  of  flexion  that  have  been  described  in  connection  with 
intestinal  obstruction,  the  flexed  bowel  was  found  either  in  the 
pelvis,  near  the  internal  inguinal  rings,  or  in  the  ileocecal  region, 
localities  where  localized  peritonitis  is  most  frequently  met  with.  If, 
after  the  reduction  of  a  strangulated  hernia,  the  replaced  loop  of 
intestine  is  or  becomes  the  seat  of  a  plastic  peritonitis,  it  forms  an 
attachment  to  the  abdominal  parietes  or  viscera  with  which  it  C(^mes 
in  contact.  In  case  the  adhesion  thus  formed  remains  firm  and  is 
not  drawn  out  in  the  form  of  a  band,  or  if  a  flexion  form  by  the 
free  portion  of  the  bowel  changing  its  relative  ])o.sition,  the  two 
bars  of  the  flexion  thus  formed,  when  in  clo.se  contact  and  the  .seat 
of  the  .same  plastic  inflammation,  become  adherent  and  the  flexion 
becomes  permanent.  If  the  continuity  of  the  bowel  can  not  be 
restored  by  separation  of  the  adhesions  in  the  operative  treatment 
of  obstruction  caused  by  flexion,  and  the  ti.ssues  at  the  seat  of  ob- 
.struction  present  no  evidences  of  gangrene,  an  anastomosis  between 
the  two  bars  of  the  flexion  should  be  made  in  preference  to  resec- 
tion   and   circular   suturing.      Another    equally   .safe    and    efficient 


8/0  FLEXION    AND    ADHESIONS. 

operation  in  such  cases  consists  in  longitudinally  incising  the  bowel 
on  the  convex  side  over  the  apex  of  the  flexion  to  the  requisite 
extent,  increasing  its  lumen,  and  connecting  the  spur  by  transverse 
suturing  in  the  same  manner  as  in  the  Heineke-Mikulicz  operation 
for  pyloric  stenosis.  Circumscribed  spots  of  gangrene  can  be  ex- 
cised and  the  wound  sutured  transversely  to  the  long  axis  of  the 
bowel,  as  this  will  cause  no  stenosis  and  will  tend  to  correct  the 
faulty  position  of  the  bowel.  As  in  cases  of  constriction  by  bands, 
if  it  is  found  difficult  to  separate  the  adhesions,  no  attempt  should 
be  made  to  liberate  the  bowel  until  a  rubber  ligature  has  been 
applied  to  each  bar  of  the  flexion.  This  precaution  is  taken  to  pre- 
vent fecal  extravasation  should  the  bowel  be  ruptured  during  the 
separation. 

ADHESIONS. 

Many  abdominal  surgeons  have  published  their  experience  in 
r-eference  to  the  occurrence  of  intestinal  obstruction  after  laparotomy. 
A  number  of  cases  of  intestinal  obstruction  that  occurred  soon  after 
ovariotomy  were  found  to  have  been  caused  by  extensive  parietal 
adhesions  of  the  intestines,  hence  the  question  of  how  such  adhesions 
are  to  be  prevented  has  been  discussed. 

P.  Mueller  has  advised  that  in  difficult  ovariotomies  adhesions  of 
the  intestines  among  themselves  and  with  the  abdominal  wall  should 
be  prevented  by  avoiding  external  compression  by  bandages  and  by 
filling  the  abdominal  cavity  with  a  physiologic  solution  of  common 
salt  (0.7  per  cent.).  For  the  purpose  of  limiting  peritoneal  absorp- 
tion he  suggests  that  the  solution  should  be  introduced  from  time 
to  time  and  finally  should  be  withdrawn  through  the  drainage-tube. 

Olshausen  has  found  in  all  the  cases  of  intestinal  obstruction 
after  ovariotomy  which  occurred  in  his  practice  that  the  obstruction 
was  caused  by  adhesion  of  an  intestinal  loop  to  the  surface  of  the 
stump.  Mueller's  prophylactic  treatment  he  considers  rational, 
especially  in  cases  where  the  operation  is  attended  by  considerable 
hemorrhage.  Schatz  holds  that  visceral  and  parietal  adhesions  of 
the  intestines  after  ovariotomy  are  a  much  more  frequent  condition 
than  is  generally  believed.  He  is  of  the  opinion  that  serious  conse- 
quences do  not  necessarily  follow  such  condition.  Gusserow^  asserts 
that  adhesions  which  have  produced  no  symptoms  are  frequently 
found  on  making  a  second  laparotomy  in  the  same  patient. 

Kaltenbach  has  for  some  time  used  a  i  :  6000  solution  of  sub- 
limate in  place  of  carbolic  acid  solution,  and  since  he  has  made  this 
change  he  has  not  observed  a  case  of  intestinal  obstruction  in  fifty- 
four  consecutive  laparotomies,  while  of  twenty-four  cases  where  car- 
bolic acid  was  used,  he  lost  two  cases  from  intestinal  obstruction. 
Kruckenberg  attributes  to  the  use  of  sublimate  an  influence  in  caus- 
ing plastic  adhesions,  and  asserts  that  since  he  has  abandoned  this 
agent  he  has  had  no  cases  of  intestinal  obstruction  after  ovariotomy. 
Sanger's  experiments  appear  to  prove  that  for  the  formation  of  a 


ADHESIONS. 


871 


firm  and  permanent  adhesion  only  one  wounded  surface  is  necessary. 
Schwarz  believes  that  parietal  adhesions  along  the  internal  surface 
of  the  abdominal  wound  are  of  frequent  occurrence,  because  intes- 
tinal loops  are  caught  in  the  furrow  of  peritoneum  along  the  line  of 
suturing,  where  an  additional  irritation  is  met  with  on  the  part  of  the 
sutures. 

Martin,  as  early  as  1865,  reported  two  cases  that  illustrate  one 
of  the  dangers  that  follow  puerperal  pelvioperitonitis.  In  one  case 
the  peritonitis  followed  a  manual  separation  of  the  placenta.  The 
patient  made  a  rapid  recovery,  but  six  weeks  later  symptoms  of 
acute  intestinal  obstruction  developed  from  which  the  patient  died 
on  the  fourth  day.  On  postmortem  the  cause  of  obstruction  was 
found  to  be  a  firm  pseudomembranous  band  that  connected  the 
anterior  surface  of  the  cecum  with  a  coil  of  the  small  intestine.  In 
the  second  case  a  metroperitonitis  followed  a  normal  delivery,  but 
yielded,  however,  to  proper  treatment  on  the  fifth  day.  During 
the  seventh  week  after  deliveiy  symptoms  of  acute  intestinal  ob- 
struction set  in,  and  the  disease  proved  fatal  after  a  few  days.  A 
similar  condition  as  in  the  first  case  was  found  at  the  postmortem. 

Hirsch  presents  at  length  the  results  of  his  observations  and 
researches  on  intestinal  obstruction  after  ovariotomy  due  to  one  of 
three  causes:  (i)  Adhesions  of  an  intestinal  loop  to  abdominal 
incision  and  occlusion  from  the  traction  of  the  cicatrix.  (2)  Asep- 
tic plastic  peritonitis  which,  by  causing  extensive  adhesions,  results 
in  immobilization  of  a  considerable  portion  of  the  intestinal  canal, 
which  leads  to  coprostasis  and  complete  obstruction.  (3)  Impac- 
tion of  an  intestinal  loop  between  a  pedicle,  treated  by  the  extra- 
peritoneal method,  and  the  abdominal  wall.  Sir  Spencer  Wells 
reported  eleven  deaths  from  this  cause  in  looo  cases  of  ovariotomy. 
Usually  the  obstruction  occurs  soon  after  the  operation,  but  several 
years  may  elapse  before  the  accident  takes  place.  The  symptoms 
are  the  .same  as  in  ob.struction  from  other  causes. 

The  prognosis  in  cases  of  obstruction  from  intestinal  adhesions 
is  extremely  unfavorable.  Of  the  fourteen  cases  collected  by  me, 
only  one  recovered  after  secondary  laparotomy.  In  view  of  the 
great  mortality  that  attends  this,  the  most  serious  complication  after 
laparotomy,  it  is  exceeding  important  to  resort  to  proper  pro- 
phylactic measures  in  all  cases  of  intra-abdominal  operations. 
In  the  first  place,  when  the  operation  is  done  in  an  a.scptic  peri- 
toneal cavity,  all  irritating  anti.septic  solutions  should  be  kept 
from  coming  in  contact  with  the  peritoneum,  as  their  local  irri- 
tant action  might  produce  a  plastic  peritonitis.  The  perito- 
neum should  not  be  unnecessarily  bruised  or  sponged,  as  a  slight 
traumatic  irritation  may  be  productive  of  a  circumscribed  adhesive 
inflammation.  Finally,  it  should  be  the  aim  of  the  surgeon  to 
restore,  if  po.s.sible,  the  continuity  of  the  peritoneal  surface  should 
any  defects  be  found  during  the  operation.  Adhesion  of  the  intes- 
tines to  the  abdominal  incision  can  be  prevented   by  spreading  the 


SyZ  BANDS    AND    DIVERTICULA. 

omentum  carefully  over  the  intestines  the  whole  length  of  the 
incision.  Limited  defects  can  be  readily  closed  by  suturing.  The 
cut  surface  of  the  pedicle  after  ovariotomy  should  be  covered  by 
stitching  the  peritoneum  over  it.  The  stump  after  supravaginal 
amputation  is  treated  in  a  similar  manner.  Parietal  and  visceral 
defects  not  amenable  to  suturing  can  be  covered  with  an  omental 
graft,  which  is  stitched  to  the  margins  of  the  defect  with  catgut 
sutures.  In  cases  of  intestinal  obstruction  due  to  extensive  adhe- 
sions after  operations  or  to  attacks  of  circumscribed  peritonitis,  it  is 
essential  to  resort  to  early  operative  treatment ;  this  consists  in 
separating  the  adhesions  and  in  restoring  peritoneal  defects  as  far  as 
possible  for  the  purpose  of  guarding  against  similar  attacks  in  the 
future.  After  the  intestine  has  been  liberated,  it  is  advisable  to  place 
the  detached  portion  in  some  part  of  the  abdominal  cavity  where  a 
similar  condition  is  less  likely  to  occur. 

BANDS  AND  DIVERTICULA. 

Strangulation  caused  by  constricting  bands  or  diverticula  results 
in  a  complexus  of  symptoms  that  resembles  the  clinical  picture  of 
a  strangulated  hernia. 

I  made  the  following  experiments  for  the  purpose  of  studying 
the  effects  of  circular  constriction  upon  the  circulation  of  the  iso- 
lated constricted  loop  of  bowel.  In  all  cases  where  the  constriction 
was  made  with  a  gauze  band,  this  was  tied  with  the  same  degree  of 
firmness  in  all,  so  as  to  determine  whether  the  same  deg-ree  of 
strangulation  would  produce  identical  results. 

Experiment  4. — Adult  cat.  A  loop  of  bowel  about  the  middle  of  the  ileum,  six 
inches  in  length,  was  tied  with  a  band  of  aseptic  gauze  with  sufficient  firmness  to  cause 
slight  congestion,  but  without  interfering  with  a  free  arterial  supply,  as  the  arteries  in  the 
ligated  portion  continued  to  pulsate  freely.  The  day  after  operation  a  few  small  fecal 
discharges  stained  with  blood  occurred.  The  cat  died  forty-eight  hours  after  the  opera- 
tion. No  rise  in  temperature  was  observed,  and  death  was  evidently  caused  by  collapse 
from  perforation.  The  loop  of  bowel  showed  gangrene  on  convex  side,  equidistant 
froni  the  point  of  strangulation,  and  a  small  perforation  that  had  given  rise  to  diffuse 
septic  peritonitis.  The  whole  visceral  and  the  parietal  peritoneum  were  uniformly 
affected,  and  the  peritoneal  cavity  contained  a  considerable  quantity  of  serosanguinolent 
fluid. 

Experiment  5. — Large  adult  cat.  A  loop  of  the  ileum  of  the  same  length  was 
tied  in  a  similar  manner  and  with  the  same  degree  of  firmness.  The  animal  absolutely 
refused  food  until  the  eighth  day.  Rise  in  temperature  occurred  on  the  second  and  third 
days.  There  was  only  one  fecal  discharge  on  the  second  day.  The  animal  was  killed 
eight  days  after  operation.  The  abdominal  wound  was  completely  united,  and  there  was 
no  peritonitis.  Four  inches  of  bowel  below  the  point  of  constriction  showed  that  partial 
reduction  had  taken  place.  The  gauze  band  was  found  completely  covered  with  adhe- 
rent omentum  and  a  thick  layer  of  plastic  lymph  that  formed  a  complete  bridge  con- 
necting the  intestine  above  and  below  the  ligature.  The  ligated  portion  showed  no 
evidence  of  defective  circulation, and  no  ulceration  underneath  the  ligature.  The  obstruc- 
tion was  coniplete,  as  no  fluid  could  be  forced  through  the  bowel,  and  in  proof  that  the 
same  condition  existed  during  life,  it  was  found  that  the  bowel  above  the  constriction 
was  considerably  dilated,  while  below  the  strangulation  it  was  empty  and  contracted. 

Experiment  6. — Large  Maltese  cat.  A  loop  of  ileum  six  inches  in  length  was 
tied  m  a  similar  manner.  On  the  third  day  feces  were  passed  stained  with  blood.  On 
the  same  day  the  temperature,  which  had  remained  nearly  normal  until  this  time,  rose  to 
105°  F.,  and  on  the  following  day  the  animal  died,  having  manifested  symptoms  of 
perforative  peritonitis  for  twenty-four  hours.      Abdominal  wound  was  united,  and  there 


BANDS    FROM    OLD    ADHESIONS.  873 

were  evidences  of  recent  diffuse  peritonitis.  Tlie  abdominal  cavity  contained  several 
ounces  of  seropuruient  fluid.  Bowel  above  constriction  was  distended  with  fluid  con- 
tents ;  below  the  obstruction,  empty  and  slightly  contracted.  The  greater  portion  of 
strangulated  loop  was  found  gangrenous  and  adherent  to  adjacent  loops  of  bowel. 
Perforation  had  taken  place  in  the  middle  of  the  loop  on  the  convex  surface,  showing 
that  gangrene  had  occurred  first  at  this  point  and  had  extended  from  here  toward  the 
ligature. 

Experiment  7. — Adult  dog,  weight  twenty-six  pounds.  In  this  case  an  opening 
was  made  in  the  mesentery  through  which  a  loop  of  the  small  intestine  six  inches  in 
length  was  pushed.  With  sutures  this  opening  was  made  sufficiently  small  so  that  its 
margins  produced  slight  strangulation.  The  dog  remained  perfectly  well  after  the 
operation,  and  was  killed  on  the  twenty-second  day.  Abdominal  wound  had  healed 
completely,  and  there  were  no  signs  of  peritonitis.  On  searching  for  the  seat  of  obstruc- 
tion it  was  found  that  spontaneous  reduction  had  taken  place,  the  site  of  perforation  in 
the  mesentery  being  indicated  by  a  recent  cicatrix. 

The  postmortem  appearances  in  these  cases  demonstrate  clearly 
that  the  gangrene  was  not  produced  by  the  primaiy  mechanical 
strangulation,  but  that  it  depended  upon  consecutive  pathologic 
changes  in  the  loop  or  its  vessels.  In  experiment  No.  5  the 
primar\'  strangulation  was  fully  as  great  as  in  the  preceding  experi- 
ment, and  yet  gangrene  did  not  occur,  and  we  have  positive  proof 
that  vascular  engorgement  in  the  ligated  portion  was  less  intense 
from  the  fact  that  partial  reduction  took  place.  In  all  cases  where 
gangrene  resulted  it  mu.st  have  been  from  an  obstruction  to  the 
return  of  blood  through  the  veins,  rather  than  from  deficient  arte- 
rial blood  supply.  If  defective  arterial  blood  supply  had  been  the 
immediate  cause  of  the  gangrene,  we  would  have  found  gangrene 
of  the  entire  loop  more  constantly,  while  every  specimen  illustrated 
that  gangrene  always  commenced  at  a  point  where  the  return  of 
venous  blood  met  with  the  greatest  resistance — viz.,  on  the  convex 
surface  in  the  middle  portion  of  the  loop.  As  in  cases  of  hernia 
or  in  aay  other  form  of  intestinal  strangulation  where  a  firm  con- 
stricting band  surrounds  the  loop  of  bowel,  the  danger  of  complete 
strangulation  is  increased  if,  by  the  peristaltic  action,  additional 
portions  of  the  intestine  are  forced  through  the  ring ;  and  the 
immediate  cause  of  the  gangrene  is  always  referable  to  obstruction 
to  the  return  of  venous  blood,  which  leads  rapidly  to  edema,  com- 
plete stasis,  and  moi.st  gangrene  in  that  portion  where  the  venous 
circulation  is  most  seriously  imjxiired.  Violent  peristalsis  inuler 
such  circum.stances  always  aggravates  the  existing  conditions,  and 
is  often  the  precursor  of  symptoms  of  complete  strangulation.  In 
such  cases  opiates  act  favorably  by  arresting  peristaltic  action,  and 
in  so  doing  may  avert  gangrene  by  preventing  the  causes  that 
otherwise  would  have  led  to  complete  venous  stasis. 

Ligamentous  bands  resulting  from  old  atlhesions  are  usually 
found  in  parts  of  the  abdominal  cavity  most  frequently  the  .seat  of 
fx.ritonitis — viz.,  in  the  pelvis  and  the  ileocecal  region.  Their 
formation  can  generally  be  traced  to  a  bioad  parietal  adhesion 
that,  by  the  peri.staltic  action  of  the  free  jjortion  of  the  intestine, 
has  become  elongated  and  often  narrowed  to  a  delicate  cord.  It 
becomes  a  cau.se  of  obstruction  when   the   migrating  or  free  end 


8/4  BANDS    AND    DIVERTICULA. 

forms  an  attachment  to  some  fixed  point,  which  then  renders  the 
band  tense  and  unyielding,  and  in  case  a  loop  of  intestine  becomes 
ensnared  underneath  it  strangulation  takes  place  in  the  same  man- 
ner as  in  strangulated  hernia,  the  constricting  cord  by  its  pressure 
causing  venous  engorgement  below  the  constriction,  and  by  the 
increased  peristaltic  action  of  the  proximal  limb  of  the  loop  forcing 
intestinal  contents  into,  but  not  through,  the  constricted  loop.  As 
in  hernia,  an  intestine  may  have  become  adherent  and  fixed  under- 
neath such  a  band  for  an  indefinite  period  of  time  without  strangu- 
lation taking  place  as  long  as  the  immediate  causes  of  strangula- 
tion are  absent.  Any  causes  that  disturb  the  mechanical  relations 
still  further  in  such  a  case,  as  a  fall,  lifting,  coughing,  the  adminis- 
tration of  an  active  cathartic,  etc.,  may  bring  on  an  acute  attack  of 
intestinal  obstruction.  The  histoiy  of  cases  of  intestinal  obstruction 
due  to  the  presence  of  a  ligamentous  band  frequently  discloses  an 
attack  of  peritonitis  through  which  the  patient  passed  perhaps  years 
before,  and  as  frequently  describes  one  of  the  above-mentioned 
proximate  causes  as  preceding  the  attack  of  intestinal  obstruc- 
tion. A  displaced  neck  of  a  hernial  sac  may  cause  obstruction  in 
the  same  manner  as  a  ligamentous  band.  Kurz  treated  such  a  case 
successfully  by  laparotomy.  The  patient,  a  man  thirty -three  years 
of  age,  had  been  the  subject  of  a  small  inguinal  hernia  for  several 
years  that  did  not  cause  much  inconvenience,  when  symptoms  of 
acute  intestinal  obstruction  set  in,  and  the  inguinal  canal,  Avhen 
carefully  examined,  was  found  empty.  The  symptoms  of  obstruc- 
tion were  very  grave,  including  a  subnormal  temperature  and  fecal 
vomiting  at  the  time  the  operation  was  performed.  Digital  explora- 
tion of  the  ileocecal  region  through  a  median  abdominal  incision 
led  to  the  discovery  of  a  ring  in  which  the  colon  had  become 
ensnared.  Reduction  by  moderate  traction  was  found  impossible, 
and  it  was  found  necessary  to  incise  the  ring  at  two  points,  when 
the  bowel,  which  was  deeply  congested,  was  readily  withdrawn. 
The  ring  was  found  displaced  four  inches  from  the  internal  ring. 
The  patient  made  a  rapid  and  satisfactory  recovery.  In  other 
instances  the  contents  of  the  hernia, — either  the  omentum  or  the 
intestinal  loop, — when  in  a  condition  of  plastic  inflammation,  may 
lead  to  the  formation  of  a  ligamentous  band  when  either  of  these 
structures  becomes  attached  near  the  internal  ring,  the  adhesion 
that  forms  lengthening  out  until  it  is  attached  to  some  other  fixed 
point.  Obre  described  the  postmortem  appearances  of  such  a  case. 
The  strangulated  loop  had  wandered  to  near  the  xiphoid  cartilage  ; 
while  between  it  and  the  inguinal  ring  a  cord  seventeen  inches  long 
was  found.  A  band  of  constriction  can  also  be  formed  by  the 
margins  of  an  opening  in  the  mesentery  or  omentum  in  which  a 
loop  of  intestine  can  become  strangulated.  In  such  cases  it  be- 
comes necessary,  after  reduction  has  been  effected,  to  close  the 
opening  by  sutures  to  prevent  a  possible  relapse  of  the  obstruction 
from  the  same  cause.     An  adherent  portion   of  omentum   in  the 


OPERATIVE    TREATMENT.  8/5 

course  of  time  may  become  a  cause  of  internal  strangulation.  In 
operating  for  intestinal  obstruction  caused  by  constricting  bands  it  is 
always  necessar\-,  after  relieving  the  point  of  constriction  first  found, 
to  search  for  additional  bands,  as  it  is  not  unusual  to  find  more  than 
one.  Obalinski  made  a  laparotomy  for  intestinal  obstruction  on 
the  third  day  after  the  appearance  of  acute  symptoms.  On  intro- 
ducing his  hand  through  a  median  incision,  he  felt  in  the  right  iliac 
region  distended  and  empty  coils,  and,  by  tracing  the  latter  in  an 
upward  direction,  found  as  the  cause  of  obstruction  two  bands, 
each  the  size  of  a  goose-quill,  extending  from  the  cecum  to  the 
abdominal  wall,  between  which  a  loop  of  intestine  thirty  centimeters 
in  length  had  become  strangulated.  Both  bands  were  ligated  and 
divided.  Bowels  moved  on  the  fourth  day,  and  patient  was  dis- 
charged cured  in  two  weeks. 

Fowler  has  met  with  two  cases  where,  at  the  autopsy,  a  second 
band  was  found  close  to  the  divided  one. 

Another  frequent  location  for  the  formation  of  bands  is  in  the 
umbilical  region,  where  the  remains  of  the  umbilical  artery  may 
become  a  cause  of  constriction.  Polaillon  opened  the  abdomen  in  a 
young  man  by  lateral  incision  on  the  right  side  for  intestinal  obstruc- 
tion one  week  after  the  appearance  of  the  first  symptoms.  As  the 
patient  was  the  subject  of  an  inguinal  hernia,  both  inguinal  canals 
were  examined  by  digital  exploration  through  this  incision,  but  noth- 
ing was  found  to  explain  the  obstruction.  The  incision  was  enlarged 
and  the  whole  hand  introduced,  and,  after  careful  exploration,  a  fal- 
ciform fold  was  found  to  the  left  of  the  median  line,  which  extended 
from  the  left  inguinal  ring  toward  the  umbilicus.  Between  the  band 
and  the  abdominal  wall  a  sac  was  found  that  contained  numerous 
coils  of  intestine.  The  whole  intestine  was  carefully  examined,  and 
finally  an  empty  loop  about  ten  inches  in  length  was  found.  The 
cause  of  .strangulation  was  the  peritoneal  band,  reduction  having 
taken  place  by  the  introduction  of  the  hand.  The  band  was  not 
divided  for  fear  of  hemorrhage.  The  patient  recovered  after  a  slight 
attack  of  peritonitis. 

Intestinal  obstruction  by  a  constricting  band  furnishes  the  sim- 
plest and  most  favorable  conditions  for  early  operative  treatment  by 
abdfjminal  .section.  Without  jirompt  surgical  treatment  a  fatal  ter- 
mination is  almost  inevitable,  as  death  results  either  from  the  mechan- 
ical eflects  of  the  ob.struction  or  the  constriction  produces  gangrene 
under  the  sharp  margin  of  the  band,  followed  by  perforation  and 
death  from  septic  peritonitis.  An  operation  undertaken  before  the 
strangulation  has  caused  great  abdominal  distention  and  .serious  text- 
ural  changes  by  pressure  or  constriction  would  be  almost  sure  to  be 
rewarded  by  succe.s.s.  Two  ca.ses  of  intestinal  obstruction  caused 
by  ligamentous  bands  reported  by  Bull  illu.strate,  in  a  mo.st  .striking 
manner,  the  imjjortance  of  early  o|)erative  interference,  lioth  cases 
were  treated  by  laparotomy,  and  the  difference  in  the  results  obtained 
was  plainly  traceable  to  the  len}4th  of  tiin<-  that  had  intervened  be- 


8/6  BANDS    AND    DIVERTICULA. 

tween  the  onset  of  the  disease  and  the  operation.  In  the  first  case 
the  operation  was  delayed  until  the  eleventh  day,  and  during  the 
separation  of  the  band  a  gangrenous  spot  in  the  bowel  gave  way, 
followed  by  fecal  extravasation.  The  circumscribed  gangrenous 
patch  was  excised,  making  a  wound  an  inch  in  length,  and  parallel 
to  the  long  axis  of  the  bowel,  which  was  closed  with  twelve  Lem- 
bert  sutures.  Death  twelve  hours  after  operation.  In  the  second 
case  laparotomy  was  performed  under  almost  identical  circum- 
stances, but  the  strangulation  had  existed  only  six  days.  In  this 
case  the  operation  was  limited  to  the  removal  of  the  cause  of  ob- 
struction, as  the  constricted  bowel  had  not  undergone  irreparable 
damage.  The  patient  recovered.  The  operative  treatment  of  the 
obstruction  in  this  form  of  intestinal  strangulation  is  usually  not 
attended  by  any  difficulties.  The  band  of  constriction,  whatever  its 
location  or  mode  of  origin,  is  traced  to  both  fixed  points  of  attach- 
ment and  excised  between  two  ligatures.  This  not  only  relieves  the 
strangulation,  but  prevents  a  possible  recurrence  of  a  similar  attack 
from  the  same  cause.  In  some  instances,  however,  the  local  condi- 
tions may  be  more  complicated.  Reali  met  with  a  case  where  it  was 
found  impossible  to  liberate  the  intestine  from  a  constricting  band ; 
he  divided  the  intestine  at  the  point  of  constriction,  and  reunited  the 
ends  again  by  circular  suturing,  his  patient  recovering.  If  on  care- 
ful examination  the  conditions  at  the  seat  of  constriction  are  such  as 
to  make  it  probable  that  the  intestine  is  the  seat  of  gangrene  from 
compression  underneath  the  band,  or  that  the  separation  of  the  band 
from  the  intestine  is  not  readily  accomplished,  no  attempts  should  be 
made  to  liberate  the  intestine  until  measures  have  been  employed 
to  guard  against  fecal  extravasation  in  the  event  of  the  bowel  being 
ruptured.  This  precaution  consists  in  emptying  the  intestine  on 
each  side  of  the  constriction  to  a  distance  of  from  two  to  four  inches 
by  displacing  its  contents  in  its  interior  between  the  thumb  and 
index-finger  and  applying  a  rubber  ligature,  which  is  passed  through 
the  mesentery  with  a  pair  of  hemostatic  forceps.  The  ligatures  are 
not  removed  until  the  bowel  has  been  liberated,  and  if  it  is  injured 
or  presents  evidences  of  gangrene,  not  until  its  continuity  has  been 
restored  by  suturing  or  excision  or  by  establishing  an  anastomosis 
after  resection. 

From  a  surgical  standpoint  in  the  causation  and  treatment  of 
intestinal  obstruction  the  appendix  vermiformis  must  be  looked  upon 
as  a  diverticulum.  The  appendix  vermiformis  may  become  a  cause 
of  obstruction  when  it  is  of  abnormal  length  and  supplied  by  a  long 
mesentery,  and  when  it  is  transformed  into  an  unyielding  band  by 
fixation  of  its  free  extremity  to  some  firm  point  by  adhesive  inflam- 
mation. Treves  reports  such  a  case.  A  boy,  six  years  of  age,  who 
had  suffered  frequently  from  attacks  of  constipation  lasting  from  a 
few  days  to  a  week  or  fortnight,  was  seized  with  violent  pain  in  the 
abdomen,  besides  exhibiting  other  symptoms  of  acute  internal 
strangulation.      On  the  fourth  day  the  pain  was  referred  to  the  iliac 


OPERATIVE    TREATMENT. 


877 

region,  where  a  resonant  swelling  could  be  located.  As  the  usual 
means  proved  of  no  avail,  laparotonn-  was  performed  on  the  fifth 
day.  About  twelve  inches  of  the  small  intestine  were  found  to  be 
tightly  strangulated  by  an  abnormal  appendix  vermiformis  whose 
free  end  had  become  fixed  to  the  iliac  fossa,  forming  a  complete 
ring  through  which  the  small  intestine  had  slipped  and  became 
strangulated.  Strangulation  was  relieved  by  division  of  the  ring. 
Patient  had  not  a  single  bad  symptom  after' the  operation.  Exci- 
sion of  the  appendix  vermiformis,  when  the  cause  of  obstruction, 
should  always  be  practised  with  a  view  to  preventing  a  similar  attack 
from  the  same  cause.  As  in  such  cases  the  process  has  undergone 
elongation  by  traction,  it  is  sufficient  to  apply  a  ligature  near  its 
base  and  then  remove  it  by  excision. 

Quite  a  number  of  cases  of  intestinal  obstruction  are  on  record 
where  the  obstruction  was  caused  by  a  diverticulum,  and  in  a  num- 


Fig-  5 '9- — A  Meckel's  diverticulum  of  the  small  intestine  (Lebert). 

ber  of  the.se  cases  the  strangulatif)n  was  successfully  treated  by 
laparotomy.  To  the  same  class  belong  bands,  the  remains  of 
obliterated  omijhalomcsentcric  vessels. 

In  185  I  Parise  published  his  paper  on  a  new  cause  of  strangu- 
lation, in  which  he  claimed  that  he  was  the  first  one  to  show  that 
strangulation  may  take  place  from  constriction  by  a  diverticulum. 
The  same  year  jionvier  described  a  case  where  a  diverticulum  of 
imusual  length,  .springing  from  the  ileum  three  feet  above  the  ileo- 
cecal valve,  encircled  a  loop  of  the  small  intestine  so  firmly  as 
to  give  rise  to  complete  obstruction.  Where  the  diverticulum  joined 
the  ileum  the  lumina  of  both  were  e(|ual  in  diameter,  but  the  diver- 
ticulum tapered  toward  its  end,  ending  in  a  bifid  extremity  that  was 
arlherent  to  intestinal  coils.  Omentum  and  abdominal  wall  furnished 
the   unyielding  points.      The   c(;nstriction   was   not   very  firm,  and 


8/8  BANDS    AND    DIVERTICULA. 

reduction  could  have  been  readily  effected  had  an  abdominal  sec- 
tion been  made. 

Meckel's  diverticulum,  as  a  remnant  of  fetal  life,  occurs  in  about 
2  per  cent,  of  individuals.  Osier  reports  finding  I2  in  550  autop- 
sies. It  is  of  interest  because  it  is  occasionally  a  cause  of  intestinal 
obstruction.  Fagge  believes  that  obstruction  takes  place  from  diver- 
ticula as  frequently  as  from  all  other  bands.  Diverticula  are  found 
in  the  lower  third  of  the  ileum,  usually  about  three  or  four  feet  from 
the  ileocecal  valve.  The  duct  is  accompanied  by  the  omphalo- 
mesenteric vessels. 

"  Early  in  the  second  month  closure  of  the  plates  forming  the 
abdominal  wall  divides  these  canals  into  an  extra-abdominal  segment 
and  an  intra-abdominal  portion.  Both  segments  atrophy  with  the 
establishment  of  placental  circulation,  the  remains  of  the  former 
being  found  as  a  cord  lying  in  Wharton's  jelly  in  the  umbilical  cord. 
The  intra-abdominal  portion  passing  from  ileum  to  umbilicus  some- 
times remains  as  an  open  canal  (fistula)  or  as  a  cord.  It  usually 
ruptures  and  entirely  disappears.  It  may  form  a  cyst.  The  duct 
may  remain  patulous  for  a  short  distance  from  the  ileum,  forming 
the  diverticulum  ilei  (Meckel's),  with  sometimes  the  cord-like  re- 
mains of  the  vessels  hanging  free  from  its  tip  or  connecting  it  with 
umbilicus  ;  with  or  without  these  the  diverticulum  may  be  found 
connected  to  mesentery,  omentum,  intestine  (large  or  small),  or 
parietal  peritoneum.  Such  connection  has  almost  universally  been 
considered  of  inflammatory  origin  ;  but  by  reports  of  examinations 
of  various  specimens  Fitz  demonstrates  that  not  infrequently  it  is  an 
omphalomesenteric  vascular  connection  "  (Putnam). 

Lamb  has  made  an  analysis  of  185  cases  of  this  remnant  of 
embryonic  life,  which,  tabulated,  give  the  following  result  in  regard 
to  the  location  of  Meckel's  diverticulum. 

In  39,  or  21  per  cent.,  the  diverticulum  was  found  between  the 
ileocolic  valve  and  one  foot  above  the  valve.  In  20  cases,  or  10 
per  cent.,  it  was  one  or  two  feet  above  the  valve.  In  22  cases,  or 
12  per  cent.,  it  was  from  two  to  three  feet.  In  4  cases,  from  three 
to  four  feet ;  in  8  cases,  from  four  to  five  feet  ;  in  4  cases,  from  five 
to  six  feet  ;  in  i  case,  ten  feet  above — in  all,  98  cases  of  the  185 
cases  reported.  In  62  other  cases  no  measured  distance  was  given, 
but  the  ileum  is  stated  or  implied.  These,  added  to  the  98,  make 
160,  or  86  per  cent.,  in  which  the  diverticulum  was  without  doubt 
in  the  ileum.  Twenty-one  cases  remain  in  which  the  anomaly  was 
in  the  jejunum  or  duodenum  ;   duodenum,  7  cases;  jejunum,  14. 

Fitz,  in  an  exhaustive  article  on  "  Persistent  Omphalomesenteric 
Remains,"  has  collected  all  material  facts  pertaining  to  Meckel's 
diverticulum  with  especial  reference  to  its  influence  as  a  cause  of 
intestinal  strangulation.  As  a  result  of  a  careful  study  of  this  subject, 
he  has  come  to  the  following  conclusions  : 

I.  Bands  and  cords  as  a  cause  of  acute  intestinal  obstruction 
are  second  in  importance  to  intussusception  alone. 


Meckel's  diverticulum.  879 

2.  Their  seat,  structure,  and  relation  are  such  as  frequently 
admit  their  origin  from  obliterated  or  patent  omphalomesenteric 
vessels,  either  alone  or  in  connection  with  Meckel's  diverticulum, 
and  oppose  their  origin  from  peritonitis. 

3.  Recorded  cases  of  intestinal  obstruction  from  Meckel's  diver- 
ticulum, in  most  instances  at  least,  belong  in  the  foregoing  series. 

4.  In  the  region  where  these  congenital  causes  are  most  fre- 
quently met  with  an  occasional  cause  of  intestinal  strangulation — 
the  vermiform  appendix — is  also  found. 

5.  It  would  seem,  therefore,  that  in  the  operation  of  abdominal 
section  for  the  relief  of  acute  intestinal  obstruction  not  due  to  intus- 
susception, and  in  the  absence  of  local  symptoms  calling  for  the 
preferable  exploration  of  other  parts  of  the  abdominal  cavity,  the 
lower  right  quadrant  should  be  selected  as  the  site  for  incision.  The 
vicinity  of  the  navel  and  the  lower  three  feet  of  the  ileum  should 
then  receive  the  earliest  attention.  If  a  band  is  discovered,  it  is 
most  likely  to  be  a  persistent  vitelline  duct — /.  £\,  Meckel's  divertic- 
ulum— or  an  omphalomesenteric  vessel,  either  patent  or  obliterated, 
or  both  these  structures  in  continuity.  The  section  of  the  band  may 
thus  necessitate  opening  the  intestinal  canal  or  a  blood-vessel  of 
large  size.  Each  of  these  alternatives  is  to  be  guarded  against,  and 
the  removal  of  the  entire  band  is  to  be  sought  for,  lest  subsequent 
adherence  prove  a  fresh  source  of  strangulation. 

According  to  Schroder,  a  diverticulum  is  supplied  with  a  mes- 
entery only  when  it  springs  from  the  lateral  aspect  of  the  intestine 
or  near  the  mesenteric  attachment.  Diverticula  on  the  convex 
surface  of  the  bowel  are  free  and  supplied  with  vessels  from  the 
intestinal  wall  (see  Fig.  519).  Meckel  found,  in  several  specimens, 
a  valve  at  the  junction  of  the  diverticulum  with  the  bowel,  and  in 
one  instance  Phoebus  found  the  opening  of  the  diverticulum  into 
the  bowel  crossed  by  a  bridge  of  tissue  connecting  its  margins. 
The  so-called  false  diverticula  always  form  on  the  concave  side  of 
the  bowel,  and  are  hernial  protrusions,  their  walls  being  composed 
of  peritoneum  and  mucous  membrane. 

Meckel's  diverticulum  may  become  a  cause  of  obstruction  when 
the  free  end  becomes  attached  to  a  fixed  point,  when  it  Ijccomcs  a 
constricting  band  if  a  loop  of  intestine  is  ensnared  underneath  it. 

In  23  ca.ses  collected  by  Cazin  and  19  by  Treves  the  attachments 
were  as  follows  : 

Near  the  umbilicus lo 

"       inguinal  ring I 

"       femoral  ring ' 

To  the  .small  gut 9 

"       cecum 3 

*'       colon I 

"       mesentery '7 

Greenhow  observed  a  case  where  a  coil  of  the  ileum  had  .slipped 
through  a  slit  in  the  mesentery  of  a  diverticulum,  which  in  this  case 
contained  omphalomesenteric  ves.sels,  and  had  become  .strangulated 


88o  BANDS    AND    DIVERTICULA. 

in  this  position.  Sometimes  a  number  of  congenital  diverticula  are 
found  in  close  proximity,  and  at  times  associated  with  other  con- 
genital defects  of  the  intestine. 

Moore  exhibited  to  the  Pathological  Society  of  London  the  in- 
testines of  a  man  aged  forty,  showing  three  diverticula  in  the  first 
three  feet  of  the  small  intestine,  and  a  congenital  stricture  at  the 
commencement  of  the  jejunum.  The  diverticula  were  each  an  inch 
long  and  about  as  much  in  diameter,  and  were  on  the  mesenteric 
side  of  the  intestine.  Their  walls  consisted  of  all  intestinal  coats, 
and  were  not  mere  hernial  protrusions.  As  long  as  the  free  end  of 
a  diverticulum  remains  unattached,  strangulation  from  this  cause  can 
not  take  place.  Strangulation  can  occur  only  when  both  extremities 
are  fixed,  either  as  a  congenital  condition  or  when  later  the  free  end 
becomes  adherent  to  some  fixed  point.  Harris  showed  a  specimen 
of  intestinal  strangulation  taken  from  a  man,  aged  twenty,  to  the  Path- 
ological Society  of  Manchester.  There  was  a  whipcord-Hke  adhe- 
sion, about  an  inch  and  a  half  long,  stretching  from  the  tip  of  Meckel's 
diverticulum  to  the  mesentery  of  the  lower  part  of  the  ileum,  and 
through  the  aperture  so  formed  a  loop  of  the  lower  part  of  the  bowel 
had  become  strangulated.  There  had  also  been  a  twist  of  Meckel's 
diverticulum,  which  had  ruptured  near  its  base,  and  death  ensued 
from  acute  peritonitis  consequent  upon  fecal  extravasation.  That 
the  danger  of  perforation  and  peritonitis  from  strangulation  by  a 
Meckel's  diverticulum  is  greater  than  when  the  obstruction  is  caused 
by  a  ligamentous  band  is  shown  by  another  case  reported  by  Hei- 
berg.  The  patient  was  a  woman,  forty  years  of  age,  who  died  in  a 
few  days  from  an  acute  attack  of  intestinal  obstruction.  At  the  ne- 
cropsy he  found  a  diverticulum  seven  inches  in  length  thirty  inches 
above  the  ileocecal  region,  which  constricted  a  loop  of  the  ileum 
twenty-one  inches  in  length.  The  free  end  of  the  diverticulum  had 
passed  between  its  base  and  the  intestine,  and  it  was  found  here, 
with  its  terminal  end  somewhat  dilated.  The  softened  wall  of  the 
diverticulum  was  found  perforated  at  one  point,  which  had  given 
rise  to  fecal  extravasation  and  septic  peritonitis.  A  somewhat  simi- 
lar mechanism  of  strangulation  by  a  diverticulum  was  described  by 
Concato.  A  man,  otherwise  in  perfect  health,  was  attacked  by 
acute  intestinal  obstruction  and  died  on  the  fourth  day.  A  loop  of 
the  small  intestine  was  found  constricted  by  a  diverticulum  located 
several  feet  above  the  ileocecal  valve,  the  free  end  of  which  had 
insinuated  itself  between  the  junction  of  the  diverticulum  with  the 
intestine  and  constricted  bowel,  thus  forming  a  firm  knot  around  the 
bowel.  That  in  most  cases  where  a  diverticulum  causes  an  obstruc- 
tion the  free  end  has  found  a  firm  point  of  attachment  is  well  shown 
by  the  cases  tabulated  by  Cazin.  He  collected  thirty  cases  of  intes- 
tinal obstruction  caused  by  a  diverticulum,  and  of  this  number,  in 
twenty-five  the  free  end  was  found  adherent.  A  diverticulum  may 
give  rise  to  symptoms  of  intestinal  obstruction  without  directly  inter- 
fering with  the  fecal  circulation.      Such  a  case  has  been  reported  by 


CONTRACTION    OF    THE    INTESTINE.  88 1 

Doran.  A  boy,  four  years  old,  died  on  the  fourth  day  after  an 
attack  of  what  resembled  acute  intestinal  obstruction  At  the 
necropsy  a  dnerticulum  the  size  of  a  pear  and  containing  a  pea  was 
found  at  the  junction  of  the  ileum  with  the  jejunum.  The  foreicrn 
body  had  caused  ulcerative  inflammation  and  perforation  of  the 
diverticulum,  and  death  from  perforative  peritonitis.  The  diverticu- 
lum was  supplied  with  a  mesenter>^  and  its  walls  were  composed  of 
all  the  tunics  of  the  bowel. 

Southey  alludes  to  another  variety  of  obstruction  caused   by  a 
diverticulum— viz.,  contraction  of  the  intestine  at  a  point  where  the 
diverticulum  is  given  off.      He  gives  a  description  of  two  such  speci- 
mens.     In  one  the  diverticulum  formed  a  band  the  size  of  a  goose 
quill,  and  extended  from  a  point  two  feet  above  the  ileocecal  valve  to 
the  abdominal  wall,  two  inches  below  the  umbilicus.      The  ileum  just 
above  the  diverticulum  was  so  constricted  as  to  admit  only  the  tip  of 
the  little  finger,  and  at  the  point  of  constriction   the   coats  of  the 
intestine,  both  muscular  and  mucous,  were  ulcerated  through,  the 
continuity  of  the  intestine  being  preserved  only  by  the  thickened 
pentoneum.      In  the  second  case  the  bowel,  at  a  point  about  eigh- 
teen inches  above  the  ileocecal  valve,  was  abruptlv  constricted  to  a 
diameter  of  about  half  an  inch,  and  a  diverticulum'  five  inches  long, 
having  a  caliber  large  enough  to  admit  the  little  finger,  passed  from 
the  intestine  and  was  attached  at  its  extremity  to  the  umbilicus.      In 
this  case  death  was  ha.stened  by  acute  diffuse  peritonitis.      That  not 
all  constricting  bands  are  the  remains  of  the  vitelline  duct  requires 
no  argument  in  speaking  of  the  operative  treatment  of  obstruction 
from  constriction  by  bands,  but  the  possibility  of  mistaking  a  peri- 
toneal fold  inclosing  unoblitcrated  umbilical  vessels  for  an  ordinary 
cicatricial  band  must  be  remembered,  and  the  necessary  sections  of 
the  band  made  between  ligatures.      If  Meckel's  diverticulum  is  found 
to  be  the  cause   of  obstruction,  this  appendage   should  always  be 
resected  in  the  same  manner  as  the  appendix.      Weir  recommends, 
in  the  excision  of  a  constricting  diverticulum,  to  apjily  a  ligature, 
and,  after  cutting   it  off,  to  stitch  the   peritoneal  surface  over  the 
divided  muscular  and  mucous  coat,  but  when   the  diverticulum  is 
nearly  of  the  .same  diameter  as  the  intestine  from  which  it  springs, 
such  a  course  Wfjuld  not  afford  ample  protection  against  perf(Mation. 
Glutton  related  a  case  of  intestinal  ob.struction  cau.sed  by  a  diver- 
ticulum, succes.sfully  treated  by  operation,  to  the  Clinical  Society  of 
London.      The  patient  was  a  boy  aged  ten  years,  who  Jiad  suffered 
on  .several  occa.sions  from  colicky  pains  lasting  f(jr  two  or  three  days, 
and  always  terminating  with  a  copious  evacuation  from  the  bowel.s. 
1  his  attack  commenced  with  vomiting  and  great  pain  in  the  abdo- 
men, which  persisted  in  spite  of  opium  treatment  for  four  days,  when 
he  was  brought  into  the  hospital  and  at  once  submitted  to  an  opera- 
tion.     On  f)pening  the  abdomen  through  the  linea  alba  a  collapsed 
portion  of  bowel  was  .sfH>n  found,  and  on   bringing  it  to  the  surface 
a  tight,  ring-like  c(jrd   c(juld  be  felt  and  sen   to   be  the  cau.se  of 
56 


882  BANDS    AND    DIVERTICULA. 

strangulation.  The  cord  was  divided  between  two  pairs  of  forceps, 
and  each  end  was  tied  with  a  catgut  ligature.  This  step  of  the 
operation  reHeved  the  bowel  from  strangulation.  On  making  an 
investigation  as  to  the  nature  of  the  band  divided,  it  was  found  that 
one  of  the  ligatures  was  situated  at  the  extreme  end  of  a  diverticu- 
lum two  inches  in  length,  and  the  other  was  placed  upon  the  wall 
of  the  same  loop  of  intestine  at  a  distance  of  about  six  inches.  A 
portion  of  the  bowel  about  three  inches  in  length  between  these  two 
points  of  attachment  was  the  part  strangulated,  and  was  of  an 
extremely  dark  color,  with  a  deep  sulcus  at  each  side.  The  boy 
made  an  uninterrupted  and  rapid  recovery. 

Glutton  explained  the  condition  as  follows  :  "  The  vitelline  duct 
had  become  obliterated  at  the  umbilicus  and  set  free  from  the 
abdominal  wall,  but,  remaining  patent  toward  the  ileum,  the  lower 
end  had  become  a  pouch-like  diverticulum  from  the  intestine.  This 
diverticulum  terminating  in  a  pointed  extremity  or  cord,  part  also 
of  the  vitelUne  duct,  which  had  been  obliterated  and  remained  float- 
ing about  among  the  intestines  till  it  became  attached  to  the  bowel 
in  contact  with  it.  The  bowel  between  the  two  points  of  attach- 
ment had  slipped  beneath  the  cord  which  united  them,  and,  being 
unable  to  extricate  itself,  had  become  strangulated." 

Maas  reports  a  case  of  diverticulum  of  unusual  size  that,  by  its 
dimensions,  caused  symptoms  of  obstruction  by  compressing  the 
rectum.  The  patient  was  a  boy  fourteen  years  of  age,  whose  abdo- 
men began  to  enlarge  soon  after  birth,  and  continued  to  do  so  until 
a  year  before  he  came  under  treatment.  During  the  last  year  the 
abdomen  became  so  much  distended  that  respiration  and  circulation 
were  seriously  impaired.  The  bowels  moved  frequently,  but  the 
stools  were  scanty  and  thin.  The  abdomen  was  enormously  distended 
and  tympanitic  on  percussion.  No  solid  tumor  could  be  detected. 
An  enema  brought  away  a  large  quantity  of  fecal  matter.  Some 
dullness  on  percussion  on  left  side  remained.  A  rectal  tube  intro- 
duced could  be  felt  apparently  over  the  tumor,  under  the  abdominal 
wall,  hence  a  diagnosis  was  made  of  congenital  hydronephrosis  on 
left  side,  or  cystic  degeneration  of  the  kidney.  An  exploratory 
puncture  in  the  left  lumbar  region  evacuated  fecal  matter.  A  median 
abdominal  section  revealed  a  swelling  covered  by  a  large  plexus  of 
veins.  The  exploration  was  not  carried  any  further,  and  the  wound 
was  closed.  The  patient  manifested  no  symptoms  of  peritonitis,  but 
soon  became  dyspneic  and  died  quite  suddenly  soon  after.  The 
autopsy  showed  that  the  swelling  was  an  immense  diverticulum  from 
the  upper  part  of  the  rectum,  containing  fourteen  quarts  of  liquid 
feces.  The  enormous  cavity  communicated  with  the  rectum  at  the 
posterior  inferior  part  of  the  pouch.  Kolliker  and  Maas  believed 
this  diverticulum  to  be  of  congenital  origin,  resulting  from  arrested 
development  of  the  blastodermic  layers. 

Poppert  reports  an  exceedingly  interesting  case  of  acute  intes- 
tinal obstruction  from  a  Meckel's  diverticulum,  where,  on  account 


INTERNAL    HERNIA.  883 

of  the  debilitated  condition  of  the  patient,  he  made  an  enterostomy 
in  the  right  ihac  region.  The  patient  improved  after  the  operation, 
and  soon  after  the  bowels  moved  spontaneously  and  continued  in 
this  condition  daily  until  the  fistula  was  closed  by  operation,  when 
symptoms  of  obstruction  reappeared  that  necessitated  reopening  of 
the  fistula.  As  the  symptoms  of  obstruction  did  not  subside  com- 
pleteh",  a  median  abdominal  section  was  made,  and,  by  following  the 
intestine  from  the  fistula  in  a  downward  direction,  the  strangulation 
by  an  adherent  diverticulum  was  found  fifty  centimeters  lower  down 
and  in  the  right  lumbar  region.  The  diverticulum  was  divided 
between  two  catgut  ligatures.  The  patient  made  a  good  recovery, 
and  the  fistula  was  later  successfully  closed  by  a  second  operation. 
Another  interesting  case  of  intestinal  strangulation  caused  by  a 
Meckel's  diverticulum  and  successful!}'  treated  by  laparotomy  is 
reported  by  McGill.  The  patient  was  a  man  aged  thirt}'  years,  who 
had  suffered  from  acute  intestinal  obstruction  for  nine  days.  The 
abdomen  was  veiy  much  distended  at  the  time  of  operation.  As 
the  seat  of  obstruction  could  not  readily  be  found  by  intra-abdom- 
inal palpation,  partial  extrusion  of  intestines  was  allowed  to  take 
place,  but  as  soon  as  three  feet  of  the  small  intestine  had  escaped, 
the  junction  of  the  distended  with  the  empty  intestine  came  into 
view.  At  this  point  a  Meckel's  diverticulum,  much  dilated  and 
about  six  inches  in  length,  passing  downward  and  forward,  was  seen 
to  be  attached  to  the  fundus  of  the  bladder.  A  loop  of  collap.sed 
intestine  pas.sed  under  the  diverticulum,  the  ob.struction  being  caused 
by  the  twisting  of  the  bowel  at  the  point  where  the  diverticulum 
was  attached.  Slight  traction  proved  efficient  in  releasing  the  bowel 
from  the  grasp  of  the  diverticulum,  and  as  soon  as  this  was  accom- 
plished, the  empty  portion  of  the  bowel  became  filled  with  the  intes- 
tinal contents.  Nothing  was  done  to  the  diverticulum.  On  the 
tenth  day  a  small  fecal  fistula  formed  at  the  lower  angle  of  the 
wound.  This  continued  for  two  weeks,  when  the  discharge  ceased 
and  the  patient  recovered  without  an\'  further  untoward  symptoms. 
The  author  believes  that  this  is  the  first  recorded  case  where  the  free 
end  of  the  diverticulum  had  its  attachment  to  the  fimdus  of  the  blad- 
der. There  can  be  but  little  doubt  tliat  the  fecal  fistula  in  this  case 
was  caused  by  a  perforation  of  the  diverticulum,  an  accident  that 
might  have  proved  fatal  if  extravasation  had  taken  place  into  the 
j)eritoneal  cavit\-,  and  that  might  have  been  avoided  had  the  diver- 
ticulum been  removed,  which  would  also  have  protected  the  i)atieiit 
with  certainty  against  a  pos.sible  recurrence  in  the  future  of  obstruc- 
tion from  the  .same  cause. 

INTERNAL  HERNIA. 
Internal  hernia  has  been  seen,  recognized,  and  studied  more  fre- 
quently at  autop.sy  than  in  the  operating  room.     An  internal  hernia 
is  a  hernia  in  which   an   intestinal   loop  becomes  incarcerated   or 
.strangulated  in  a  physiologic  or  preformed  pouch  or  pocket.     The 


884 


INTERNAL    HERNIA. 


two  spaces  where  this  accident  is  most  Hable  to  occur  aie  the  fora- 
men of  Winslowand  the  duodenojejunal  fossa — cavum  Treitzii.  In 
the  former  location  the  hernia,  as  a  rule,  is  larger  than  in  the  latter, 
owing  to  the  difference  in  the  size  of  these  two  normal  spaces.  Other 
spaces  of  less  importance  and  rarely  the  seat  of  internal  hernia  are 
in  the  region  of  the  sigmoid  flexure  and  cecum. 

The  only  successful  operation  for  strangulated  internal  hernia  so 
far  reported  was  performed  by  Sonnenburg.      Although  the  exact 


Fig.  520. — Hernia  into  the  fossa  duodenojejunalis  (after  Cooper). 

location  of  the  hernial  sac  could  not  be  demonstrated  at  the  time  the 
operation  was  performed,  the  clinical  symptoms,  the  size  and  condi- 
tion of  the  strangulated  loop,  left  but  little  doubt  that  it  was  a  hernia 
of  the  duodenojejunal  fossa. 

No  intj^avitam  diagnosis  has  ever  been  made  in  internal  strangu- 
lated hernia.  Herniae  of  the  foramen  of  Winslow  and  of  the  duodeno- 
jejunal  fossa  have  much  in  common.  In  both  locations  the  upper 
portion  of  the  small  intestine  usually  constitutes  the  hernial  contents. 
The  pain  is  referred  to  a  point  half-way  between  the  ensiform  carti- 


INVAGINATION. 


885 


lage  and  umbilicus,  and  a  little  to  the  left  of  the  median  line.  Dur- 
ing the  early  stages  of  strangulation  a  tympanitic  tender  swelling 
can  be  felt  in  that  location  if  the  hernia  is  large,  but  this  swelling 
soon  becomes  indistinct  or  disappears  entirely  by  distention  of  the 
intestines  above  the  seat  of  obstruction.  Herniae  in  the  right  and 
left  iliac  fossae  are  even  more  obscure  in  their  clinical  manifestations. 
Early  treatment  by  abdominal  section  is  the  only  treatment  that 
offers  any  hope  whatever  of  saving  life.  A  long  median  incision 
and  partial  evis- 
ceration are  nec- 
essary to  secure 
access  to  the 
hernia  and  for  its 
direct  treatment. 

INVAGINATION. 
By  invagina- 
tion or  intussus- 
ception is  under- 
stood a  telescoping 
of  one  section  of 
the  intestine  into 
another,  with  very 
few  exceptions  in 
a  downward  direc- 
tion. From  a  sur- 
gical standpoint 
invagination  is  the 
most  important 
form  of  intesti- 
nal obstruction. 
Leichten.stern  and 
Leubuscher  have 
made  careful  ex- 
perimental -Studies 
to  explain  the 
mechanism  and 

pathologic  conditions  that  give  ri.se  to  this  kind  of  intestinal 
obstruction,  but  in  the  following  experiments  this  part  of  the 
subject  was  ignored,  and  the  invaginations  were  made  by  direct 
manipulation.  It  was  found  impossible  to  make  an  invagination  at 
any  point  so  long  as  the  bowel  was  in  a  condition  of  contraction  ; 
consequently  it  was  always  found  neces.sary  to  wait  until  the  peris- 
taltic wave  had  i)assed  by,  or  to  cause  relaxation  by  firm  [)ressurc 
continued  for  several  minutes.  Usually  it  was  found  ea.sy  to  pro- 
duce an  invagination  of  the  bowel,  when  in  a  state  of  relaxation,  by 
indenting  one  .side  of  the  bowel,  and  jjushing  tiie  pouch  forward  with 
a  blunt  instrument  until  the  entire  lumen  of  the  inte.sline  had  passed 


Vi\r,  521. — Diaphragmatic  hernia  (after  Cooper). 


886  INVAGINATION. 

into  the  section  of  the  bowel  below.  After  this  was  accomplished, 
further  invagination  was  readily  effected  by  manipulation,  consisting 
in  pushing  the  intussusceptum  and  intussuscipiens  gently  toward 
each  other.  After  it  was  ascertained  by  experience  that  disinvag- 
ination  frequently  takes  place  spontaneously,  the  intussusceptum 
was  sutured  to  the  neck  of  the  intussuscipiens  for  the  purpose  of 
maintaining  the  invagination.  But  even  this  expedient  did  not 
always  succeed  in  retaining  the  malposition,  as  spontaneous  reduc- 
tion was  observed  in  several  of  these  cases.  These  experiments 
would  certainly  tend  to  prove  that  temporary  invagination  is  of 
rather  frequent  occurrence,  and  may  account  for  many  painful  bowel 
disorders  of  short  duration  in  infants  and  children. 

Experiment  13. — Adult  cat.  The  lower  portion  of  the  ileum  and  the  cecum  and 
upper  portion  of  the  colon  were  drawn  forward  into  an  incision  through  the  linea  alba, 
and  five  inches  of  the  ileum  were  pushed  into  the  colon  through  the  ileocecal  valve, 
when  the  parts  were  replaced  and  the  abdominal  wound  closed.  For  six  days  the 
animal  had  a  temperature  from  102.6°  to  105°  F.,  and  suffered  from  tenesmus.  The 
stools  contained  mucus  and  blood.  After  the  sixth  day  the  symptoms  due  to  invagina- 
tion subsided,  and  were  replaced  by  symptoms  of  peritonitis.  The  animal  was  killed 
twenty-two  days  after  operation.  There  was  great  emaciation.  The  abdominal  wound 
had  united  completely  and  there  were  evidences  of  diffuse  purulent  peritonitis.  The 
disease  had  evidently  commenced  in  the  ileocecal  region,  as  at  this  point  the  pathologic 
changes  were  found  most  advanced.  There  was  complete  spontaneous  reduction  of  the 
invagination,  and  the  colon  was  greatly  distended  and  intensely  congested. 

Experiment  14. — Large  adult  cat.  Invagination  was  made  in  the  lower  part  of 
the  ileum.  Length  of  intussusceptum,  three  inches.  For  nine  days  the  scanty  fecal 
discharges  contained  mucus,  and  at  times  blood.  On  the  ninth  day  the  temperature  reg- 
istered 105°  F.  There  was  absolute  refusal  of  food,  and  only  occasional  vomiting  ; 
death  occurred  on  the  thirty-third  day  after  invagination.  Abdominal  wound  healed. 
There  was  small  ventral  hernia,  but  no  peritonitis.  Apparently  the  greater  portion  of 
the  intussusceptum  had  disappeared  by  sloughing,  and  the  subsequent  healing  process  had 
produced  an  acute  flexion  at  the  neck  of  the  intussuscipiens.  Firm  adhesions  occurred 
between  the  peritoneal  surfaces  in  the  concavity  of  the  flexion,  nearly  an  inch  in  length. 
Above  this  point  the  intestine  was  enormously  dilated  and  distended  with  fluid  contents. 
Below  the  obstruction  the  bowel  was  found  contracted  and  empty.  Water  could  not  be 
forced  through  the  obstruction  from  either  direction.  On  slitting  open  the  bowel  in  a 
longitudinal  direction  it  was  found  that  the  lumen  at  the  point  of  flexion  was  contracted 
to  such  an  extent  that  only  a  fine  probe  could  be  passed.  On  the  concave  side  of  the 
flexion  the  mucous  membrane  presented  a  prominence  marked  by  a  number  of  longitu- 
dinal ridges.  These  folds  had  undoubtedly  acted  like  valves  in  completely  preventing 
the  passage  of  intestinal  contents,  and  later  of  the  injection  of  water.  Death  in  this 
case  resulted  from  intestinal  obstruction  caused  by  cicatricial  contraction  after  the  slough- 
ing of  the  invaginated  portion  of  the  bowel. 

Experiment  15. — Adult  cat.  Two  inches  of  the  ileum  were  invaginated  into  the 
colon  and  fixed  by  two  fine  silk  sutures  at  the  neck  of  the  intussuscipiens.  For  two  days 
after  the  invagination  the  stools  were  scanty  and  contained  mucus  and  blood.  On  the 
third  day  the  abdominal  cavity  was  reopened  by  an  incision  along  the  outer  border  of  the 
right  rectus  muscle,  and  the  invaginated  bowel  was  drawn  forward  into  the  wound.  No 
peritonitis  followed.  The  bowel  at  point  of  operation  was  very  vascular,  and  the  neck 
of  the  intussuscipiens  was  covered  with  plastic  exudation.  The  sutures  were  removed, 
and  the  rectum  and  colon  distended  with  water  for  the  purpose  of  effecting  reduction. 
As  soon  as  the  colon  had  become  thoroughly  distended,  the  adhesions  gave  way  with 
an  audible  noise,  and  complete  reduction  followed  in  such  a  manner  that  the  portion  last 
invaginated  was  first  reduced.  After  reduction  had  been  accomplished,  the  injection 
was  continued  to  test  the  competency  of  the  ileocecal  valve.  As  soon  as  the  cecum  was 
well  distended  the  fluid  passed  readily  through  the  valve  into  the  small  intestine,  show- 
ing that  the  valve  had  been  rendered  incompetent  by  the  invagination.  The  force 
required  to  overcome  the  adhesions  in  the  reduction  of  the  invagination  was  sufficient  to 
rupture  the  peritoneal  covering  of  the  large  intestine  in  three  different  places,  the  rents 
always  taking  place  parallel  to  the  bowel.  The  animal  died  on  the  following  day  with 
symptoms  of  diffuse  peritonitis. 


EXPERIMENTS.  gg- 

Experiment  i6.— The  ileum  was  invaginated  in  a  cat  a  few  inches  above  the  iieo 
cecal  region  ni  an  upward  direction  to  the  extent  of  two  inches.  At  the  time  the  invasr 
ination  was  made  the  intussuscipiens  contracted  tinnly.  In  consequence  of  this  a  tear 
occurred  in  its  peritoneal  covering  in  a  direction  parallel  to  the  bowel.  The  stools  were 
few  and  scanty.  On  the  fourth  day  the  animal  died  of  perforative  peritonitis  Abdom 
inal  wound  had  not  united,  but  the  peritoneal  wound  was  closed  by  omental  adhesions 
Spontaneous  reduction  of  half  an  inch  of  the  invagination  had  taken  place.  Reduction 
by  traction  was  tound  impossible  on  account  of  firm  adhesions  about  the  neck  of  the  in 
vagination.  Recent  ditifuse  peritonitis  caused  by  two  perforations,  one  at  the  neck  of  the 
intussusceptum  on  the  mesenteric  side,  and  the  other  a  little  to  one  side  of  this  one  and 
on  the  proximal  side  of  bowel.  The  perforation  resulted  from  beginning  sloughing  of 
the  invaginated  portion  of  the  bowel.  About  two  inches  above  the  invagination  the 
bowel  was  acutely  flexed  toward  the  mesenteric  side  by  recent  f^rm  adhesions.  Flexion 
was  undoubtedly  caused  by  circumscribed  plastic  peritonitis  and  increased  peristalsis 

Experiment  17.— Large  adult  cat.  Descending  invagination  of  the  ileum  to  tlie  ex- 
tent of  two  inches  in  the  upper  portion  of  this  part  of  the  bowel  was  made.  On  the  second 
and  third  days  the  .scanty  discharges  from  the  bowel  were  bloody.  Temperature  from 
the  second  day  after  operation  varied  between  103.4°  F.  and  105.4°  F.  Death  occurred 
from  perforative  peritonitis  on  the  seventh  day  after  invagination.  Abdominal  wound 
was  found  united.  Recent  diffuse  peritonitis  resulted  from  a  perforation  at  the  neck  of 
the  invagination  on  the  mesenteric  side.  There  were  gangrene  of  intussusceptum  and 
partial  separation,  which  had  again  caused  a  sharp  flexion  of  the  bowel  at  the  neck  of  the 
invagination.  Above  the  seat  of  obstrucUon  the  bowel  was  dilated  and  distended  with 
fluid  contents  ;  below,  empty  and  contracted. 

Experiment  18. — Young  cat.  Invagination  of  ileum  into  a.scending  colon  to  the 
extent  of  three  inches.  For  a  week  after  operation  there  was  frequent  tenesmus,  followed 
by  mucous  discharges  mixed  with  blood.  The  temperature  during  this  time  varied  from 
102.6°  to  105°  F.  After  this  the  animal  improved,  and  was  in  good  condition  when 
killed,  fourteen  days  after  operation.  Abdominal  wound  was  found  united,  and  there 
were  no  omental  adhesions  or  peritonitis.  Firm  union  had  taken  place  between  the 
serous  surfaces.  No  dilatation  of  bowel  occurred  above  seat  of  obstruction.  Intussus- 
ceptum was  not  gangrenous,  its  lumen  being  about  the  size  of  an  ordinary  lead-pencil. 
It  was  found  impossible  to  reduce  the  invagination  by  traction  or  by  forcible  injection 
of  fluid  from  below.  When  the  traction  was  increased,  the  peritoneal  surface  of  the  neck 
of  the  intussuscipiens  ruptured  in  a  longitudinal  direction. 

Experiment  19. — Large,  adult  cat.  Six  inches  of  the  ileum  were  invaginated  into 
the  colon.  Frequent  bloody  discharges  occurred  until  the  third  day,  when  the  abdomen 
was  reopened  and  the  neck  of  the  intussu.scipiens  exposed  to  sight,  so  as  to  observe 
directly  the  mechanism  of  disinvagination  by  rectal  injection  of  water.  As  soon  as  the 
colon  was  \vell  distended,  the  adhesions  at  the  neck  of  the  intu.s.su.scipiens  began  to  give 
way,  and  complete  reduction  followed,  as  the  adhesions  gave  way  under  the  pressure 
from  below.  The  abdominal  wound  was  again  closed  and  dressed  in  the  usual  manner. 
The  animal  recovered  completely  from  the  ojieration,  and  was  killed  twenty  four  days 
after  the  first  operation.  Abdominal  wound  was  well  united.  In  the  ileocecal  region 
numerous  adhesions  were  found  around  the  portion  of  the  bowel  that  had  been  invnginated 
and  subsequently  reduced. 

Experiment  20.  —  Invagination  of  colon  into  colon  was  commenced  about  llie 
middle  of  the  bowel  and  advanced  as  far  as  the  cecum.  On  the  .second  day  bloody  dis- 
charges occurred  from  the  bowels.  Animal  was  killed  five  days  after  operation.  Exter- 
nal wound  was  united  only  on  peritoneal  .side,  and  invagination  was  coin|)IeleIy  reduced. 
Localized  plastic  peritonitis  was  limilt-d  to  the  portion  of  the  bowel  thai  had  been  invag- 
inated ;  otherwise  the  peritoneum  and  intestines  were  in  a  healthy  condition. 

ExPKRi.MKNT  21. — Cat.  Invagination  of  colon  into  colon  to  the  extent  of  four 
inche.s  was  made.  The  .subsequent  symptoms  indicated  the  existence  of  invagination 
only  for  a  .short  time,  and,  after  they  had  subsided,  were  followed  by  evidence  of  periton- 
itis. Death  occurred  on  the  nineteenth  day  after  the  invagination.  Abdominal  wound 
was  well  united.  There  were  evirlences  of  diffuse  purulent  |)erilonilis.  and  the  under 
surface  of  the  diaphragm  was  covered  with  a  plastic  lymph.  Although  sought  for,  no 
perforatifju  could  be  found  in  the  disinvaginated  bowel,  but  as  the  jjerilonilis  appeared  to 
have  started  at  the  site  of  operation,  it  is  probable  that  infection  took  jilace  through  the 
paretic  walls  of  the  disinvaginalcfj  bowel. 

P-XI'IKIMKNT  22. — Same  kind  of  invagination  made  in  a  cat  as  in  the  preceding 
ca.se.  I' or  two  days  the  stools  were  frequent,  .scanty,  and  contained  mucus  and  blood. 
After  this  the  animal  remained  in  good  conrlition  until  it  was  killed,  thirty-five  days  after 
the  invagination.  The  abdominal  cavity  showefl  no  trace  of  inflammation.  The  invagin- 
ation was  completely  reduced,  ami  the  entire  colon  presented  a  iic.rm;il  n|pp(iiiance. 


888  INVAGINATION. 

With  the  exception  of  experiment  No.  i6,  the  invagination  was 
always  made  in  a  downward  direction.  In  the  case  of  ascending 
invagination,  gangrene  of  the  intussusceptum  and  perforation  re- 
sulted in  death  from  diffuse  peritonitis  on  the  fourth  day,  after  par- 
tial spontaneous  reduction  had  taken  place.  In  experiments  No. 
15  and  No.  19,  both  cases  of  ileocecal  invagination,  complete  reduc- 
tion was  effected  by  distention  of  the  colon  with  water ;  in  the  first 
case  the  force  required  to  accomplish  this  result  was  sufficient  to 
produce  multiple  longitudinal  lacerations  of  the  peritoneal  surface 
of  the  distended  bowel,  which  undoubtedly  were  responsible  for 
death,  on  the  following  day,  from  diffuse  peritonitis  ;  while  in  the 
second  case  no  such  accident  occurred  and  the  animal  recovered, 
although  the  abdominal  wound  was  reopened  for  the  purpose  of 
observing  the  mechanism  of  reduction  by  this  method  of  procedure. 
In  one  case  of  ileocecal  invagination,  experiment  No.  18,  the  intus- 
susceptum remained  in  situ  after  the  invagination,  and  became  so 
firmly  adherent  to  the  intussuscipiens  that  even  in  the  specimen 
reduction  by  traction  was  found  impossible.  In  this  case,  although 
the  lumen  of  the  invaginated  portion  barely  permitted  the  introduc- 
tion of  an  ordinary  lead-pencil,  no  symptoms  of  obstruction  were 
manifested  during  life,  and  the  bowel  above  the  invagination  was  not 
found  dilated  after  death.  In  experiment  No.  14  the  sloughing  of 
the  intussusceptum  led  to  cicatricial  contraction  of  the  bowel  and 
flexion  at  the  site  of  invagination,  conditions  that  resulted  in  death 
from  obstruction  twenty-three  days  after  invagination.  The  great 
dangers  that  attend  sloughing  of  the  invaginated  portion  are  cir- 
cumscribed gangrene  and  perforation  of  the  intussuscipiens  at  the 
neck,  and  death  from  perforative  peritonitis,  as  illustrated  by  experi- 
ments No.  16  and  No.  17.  Experiment  No.  16  illustrates  that 
ascending  invagination,  should  it  occur,  is  not  more  likely  to  be  re- 
duced spontaneously  than  the  more  common  form  of  descending 
invagination.  These  experiments  also  demonstrate  conclusively  that 
the  danger  attending  the  invagination  increases  the  higher  it  is 
located  in  the  intestinal  canal,  being  greatest  when  it  is  situated  high 
up  in  the  tract  of  the  small  intestine,  and  gradually  less  as  the  ileo- 
cecal region  is  approached.  The  ileocecal  form  is  less  dangerous, 
as  spontaneous  reduction  is  more  likely  to  take  place,  and  gangrene 
of  the  intussusceptum,  when  it  occurs,  does  so  at  a  later  period,  after 
firm  adhesions  about  the  neck  of  the  intussuscipiens  have  formed,  a 
condition  that  is  well  adapted  to  prevent  perforation.  Of  the  three 
invaginations  of  the  colon,  experiments  No.  20,  21,  and  22,  com- 
plete spontaneous  reduction  took  place  in  all  of  them  from  the  first 
to  the  fourth  day,  and  in  only  one  of  them  was  the  result  fatal — in 
experiment  No.  21,  where  purulent  peritonitis,  either  from  infection 
through  the  operation  wound  or,  what  is  more  probable,  through 
the  damaged  wall  of  the  colon,  occurred  and  was  the  cause  of  death 
on  the  nineteenth  day  after  the  invagination.  Experiments  No.  1 5 
and  19  prove  both  the  danger  and  the  utility  of  distention  of  the 


ETIOLOGY.  gg^ 


colon  in  cases  of  ileocecal  and  colic  invaoinations       Ac  o       i      .u 
longerthe  invagination  has  existed   the  fi  nier    L  .W        ''      '  '^! 
consequently  the  ..eater  the  danger'  "^ ^Z    oo  ^e  Sl^Xt 
th,s  measure  ni  reducing  the  invagination.      In  resoX    o  th is^x 
ped^ent  n.  the  reduction  of  an  ileocecal  invagination^  ^o  ^h  t^^^^^ 
e^,t  importance  to  relax  the  abdominal  wall  comoletelv  hv  r,F 
the  patient  fully  under  the  n.fluence  of  an   an"  t'het   '  l^TI 
order  to  add  to  the  distending  force  as  much  as  possible' by  t'viti 
tion,  the  patient  should  be  inverted  and  the  injection  shoufd  .it  -1 
be  made  very  slowly  and  with  requisite  care,  to  pleven  tr  ptu  eo7 
he  peritoneal  coat  by  rapid  o^•erdistention.      When  the  obSi^ction 
s  located  beyond  the  ileocecal  valve,  no  reliance  can  be  placed  upon 
this  measure,  as  can  be  seen  from  the  following  experiments  made 


^■^^nS^Yon^l^ZS;^^^^^^^  '^^  -«-"«  °f  ^ther,  an  incision  suffi- 

the  linea  alba  of  a  Zi       xThSju^^l'T'--  f '?f '^  '  '°  "^'^^  "'"^  '"'^^^  'trough 

ally  the  escape  of  even  a  c  r";  of  fluiS^  1  t  e  Lum"  The""""'  r-"""^.  ^^-tu- 
was  overcome  only  by  ^c'^/V/LJ^^  nf  h.  '*'^  "^"™-  .  ^e  compelency  oi  the  valve 
margins,  and  thus  Illowe/a  fine     r.lmf        ^    T'   '"'""^  "mechanically  separated  its 

while  the''odywas'in;;r\ed''wal?'jir"-  VT  ""'  ^"">'  "^"''^'^^^  ^''^  ^'''-'  -^ 
with   adequate  f^^^rcebvnSnrof.r^l^  '"'""'  '"  '"^^'^"'  quantity,  and 

overcome 'theMSnc^  Xr^rbv  tEelKLTv^; '°  S  t,'':-''"^T^"''*^'  '" 
could  be  dearly  mapped  out  by  peVcus^ion^T  a7pat!;n  fef^r       T^"  IdV^e'   IntX 

;;pS;;id:s  or.£:c.d.'  "^'^'^^ "'  ^'^  ^^""'"  ^^'^^  ^"  ■-•''"  -^'''^  --  •■-'-!"'' 

one  Sv'ihir.w'  ^5--'''h''^  experiment  was  conducted  in  the  sam..  way  as  the  foregoing 

T'entire  alimentaTv  cZu  '""■""'•  '''T  ^'''''"  ^^  ''"^^'  "<■  ^-"  ■•  ^^  ^--^  "-'  K^ 
fnr  Ji?,h^  /        .       ^  rr    ""i  ^'■'''"  '*""'*  ^''  "i"'"''-     ''"'i^'  animal  was  not  killed    and   livc.l 

IxamSl.ifr'  •:"^'^"'f  "'"'  ^''^^''^  ^'"•^-  ^^"'^  •^>'"l>"'"^^  '""  ileocolitis      A  pus,  norUM 

feavTno  :".uTh";  ,r"''  '",  '^'r  --' .^'"'-K'^  ''-  sympton.s  n-anifcstcd 'du  g  i  ' 
^en  th^t         hi?.  ^  '■^•'"'u'^''  ^':;""  '"  ""'-^  '■"'^'^'^■''  f^y  "'e  injection.      It  will  thus  In- 

tern   he       .1     r''  '"'^'^^^^''^^■'■'^  fl"i'J  -»^  forced  beyond  the  ik-ocecal  valve,  in  two 
.heTa  g^   melTne  Thd"M'"r,"- '  I  -'-^'r'-''''''''^  '--'-"'■"•"•  "<■  "-  I'-'—I  coat  o 
Ide    and  diJ       i'.h  T      "f  '"'T^'  ■""  '^'■'"■''  i'""'e'liately  after  .he  experiment  was 

therT-fore  U'Cl  .  ''"".'^'^'  ^'''.'.^■e  '"  the  .rea.ment  of  in.es.innl  obs.ru<-.ion  must 
Ie."r.ed  ,^  "'"'"   '"   "'"  ''^''"   "^  •-•  ''--"'^erous  expedient,  an.l  should  never  be 

Rectal  insufflatir,n  of  hydrogen  gas  or  air  is  the  <.nly  direct 
mechanical  agent  that  should  be  emph.xcd  in  recent  acute  and 
chrome  .nvaginat.r,n,  with  a  view  to  effecting  reduction  short  of  the 
use  r,f  the  knife. 

Etiology.  — Invagination  as  an  isolated  iMicompli(  ated  affection 


890  INVAGINATION. 

is  notably  a  disease  of  infancy  and  childhood.  In  adults  and  the 
aged  it  is  often  compUcated  by  intestinal  tumors  or  stenosis,  condi- 
tions that  take  an  important  part  in  the  invagination. 

In  regard  to  the  age  of  patients  suffering  from  invagination,  it 
may  be  said  that  50  per  cent,  of  all  cases  occur  in  persons  under 
ten  years  of  age.  According  to  Heusner,  in  children  invagination 
is  the  cause  of  obstruction  in  three-fourths  of  the  cases  of  intestinal 
obstruction.  If  every  case  of  invagination  were  tabulated,  it  would 
be  seen  that  one-fourth  of  the  whole  number  would  be  children 
under  one  year  of  age.  The  acute  form  is  most  frequent  in  the 
young,  and  the  chronic  variety  between  the  ages  of  twenty  and 
forty. 

Leichtenstern  has  studied  the  mortality  that  attends  invagination, 
and  in  557  cases  in  which  the  termination  was  known,  the  result 
was  as  follows  : 

Age.  Total  Mortality.         Mortality  of  Cases  without 

Elimination  of  Gangrenous  Portion. 

1  year      88  \  g^ 

2  years 82  j 

2-10    " •  72  80 

11-20    "        63  86 

21-40    "        63  82 

41-50    "        631 

51-60    "        71  I  ^°  . 

More  than  60  years 77 

From  this  table  it  will  be  seen  that  the  mortality  up  to  the  age 
of  forty  increases  with  the  diminution  of  the  age  of  the  patients, 
being  greatest  in  infants  and  children,  in  whom  the  invagination 
usually  pursues  an  acute  course. 

A  long  mesentery  furnishes  an  anatomic  predisposing  cause,  and 
violent  or  irregular  peristalsis  is  undoubtedly  the  most  potent 
exciting  cause.  Whether,  during  the  process  of  invagination,  that 
section  of  the  bowel  that  becomes  the  intussusceptum  is  telescoped 
into  a  relaxed  section  of  the  bowel  adjacent  by  active  peristalsis,  or 
whether  the  intussusceptum  is  aspirated,  as  it  were,  into  the  intus- 
suscipiens,  is  a  question  that  has  not  been  fully  determined.  It  is 
probable  that  intussusception  may,  and  does,  take  place  in  both 
ways. 

No  effort  will  be  made  here  to  elaborate  upon  the  views  enter- 
tained by  different  authors  and  experimenters  concerning  the 
mechanism  of  the  ordinary  forms  of  invagination,  but  from  a 
surgical  aspect  it  is  important  to  allude  to  some  of  the  physiologic 
conditions  that  produce  the  invagination,  and  at  the  same  time  com- 
plicate the  treatment.  Mr.  Bellamy  has  described  the  case  of  a 
very  rare  form  of  intestinal  obstruction,  due  to  invagination  of  a 
portion  of  the  small  intestine  in  the  walls  of  the  rectum,  success- 
fully treated  by  abdominal  section.  The  obstruction  had  been 
complete  for  nine  days.  The  patient  was  a  female  who  had  been 
subject  to  obstinate  constipation,  and  on  three  occasions  the  reten- 
tion of  fecal   matter  had  given   rise  to  serious  symptoms,  which, 


INVAGINATION     BY    TUMOR.  ggi 

however,  had  always  yielded  to  ordinary  means.  On  admission 
into  the  liospital  a  hard  swelHng  could  be  felt  in  the  left  iliac  fossa, 
in  the  region  of  the  inguinal  canal  and  sigmoid  flexure.  Manual 
examination  of  the  rectum  disclosed  an  obstruction  in  the  upper 
part  of  this  portion  of  tlie  intestine.  As  the  symptoms  of  obstruc- 
tion became  urgent  and  failed  to  yield  to  ordinary  treatment,  ab- 
dominal section  was  performed  by  enlarging  the  incision  upward 
and  obliquely  outward,  having  previously  exposed  the  left  external 
inguinal  ring,  which  had  been  the  seat  of  an  old  hernia.  On  intro- 
ducing the  hand  into  the  abdomen  it  was  ascertained  that  the 
swelling  in  the  iliac  region  was  composed  of  a  knuckle  of  small 
intestine  that  was  obviously  invaginated  in  the  anterior  aspect  of  the 
first  part  of  the  rectum,  and,  in  addition,  there  were  felt  what 
appeared  to  the  touch  to  be  bands  of  organized  lymph,  stretching 
across  in  the  same  place,  and  probably  the  result  of  a  former  cir- 
cumscribed peritonitis.  The  operator  introduced  his  right  hand  into 
the  rectum  and  pushed  the  prolapsed  mass  upward  and  toward  his 
left  hand,  which  was  in  the  pelvic  cavity,  at  the  same  time  breaking 
down  the  adhesions  and  gently  drawing  out  the  knuckle  from  its 
imprisoned  position  and  freeing  it  from  the  peritoneal  fold.  The 
symptoms  of  obstruction  subsided  promptly,  and  the  patient,  after 
having  passed  through  a  mikl  attack  of  peritonitis,  made  a  com- 
plete recovery.  In  examining  the  literature  of  the  subject  Bellamy 
had  been  unable  to  find  an>'  case  where  abdominal  section  had  been 
performed  for  a  similar  condition,  although  Lockhart  described 
this  form  of  hernia,  stating,  however,  that  he  had  never  known  an 
operation  to  be  necessary. 

The  cause  of  a  chronic  invagination  is  often  a  tumor  attached 
to  the  inner  surface  of  the  bowel.  The  tumor,  by  its  weight,  drags 
the  portion  of  intestine  to  which  it  is  attached  into  the  segment  of 
bowel  below,  the  descent  of  the  intu.ssusceptum  being  often  very 
slow.  In  these  cases  the  tumor  is  always  found  attached  to  the 
apex -of  the  intussusceptum.  Invagination  caused  by  tiniiors  is  most 
frequent  in  the  large  intestine,  as  the.se  are  more  frequently  the  .scat 
of  tumors  than  the  intestinal  canal  above  the  ileocecal  valve. 

Tuffier  reports  a  case  of  invagination  operated  on  by  Marchand 
that  is  of  special  interest  on  account  of  the  rare  condition  found, 
which  had  led  to  the  invagination.  The  patient  was  a  woman  forty- 
three  years  of  age,  who  had  suffered  from  a  gradually  increasing 
intestinal  ob.struction.  Rectal  examination  revealed  a  tumor  that 
had  dragged  an  upper  .segment  of  the  bowel  with  it  into  the  rectum. 
Marchand  opened  the  abdomen  in  the  left  inguinal  region,  and  found 
an  invagination  of  the  sigmoid  flexure  into  the  rectum.  Reduction 
was  found  impfjssil>le.  An  artificial  anus  was  establishcfl  after  the 
method  of  Littre.  Death  followed  on  the  filth  day.  The  necrop.sy 
showed  diffu.se  pcrit(;nitis,  which,  in  the  small  pelvis,  had  assumed  a 
suf)purative  type.  The  sigmoid  flexure  was  foutui  invaginated  to 
the  dejjth   of  six   centimeters  ;   the  .serous  surfaces  were  adherent, 


892  INVAGINATION. 

and  gave  way  only  to  considerable  traction  force.  A  pedunculated 
lipoma  was  attached  to  the  apex  of  the  intussusceptum. 

Kulenkampff  reports  a  case  of  a  woman,  aged  thirty-nine  years, 
who  had  suffered  from  incomplete  obstruction  of  the  bowels  with 
bloody  discharges  from  the  anus  for  six  months.  During  the  prog- 
ress of  the  disease  a  mass  that  was  thought  to  be  a  polypus  could 
be  felt  in  the  rectum.  This  proved  to  be  a  papilloma  (probably 
malignant)  that  originated  in  the  sigmoid  flexure,  and  had  been  the 
cause  of  the  invagination  of  that  part  of  the  colon  into  the  rectum. 
The  entire  mass,  including  the  intussusceptum,  was  removed 
through  the  rectum.  An  adherent  coil  of  intestine  was  accident- 
ally wounded,  and  the  wound  was  at  once  closed  by  suturing. 
The  operation  was  followed  by  an  aggravation  of  the  symptoms  of 
obstruction  ;  on  the  tenth  day  laparotomy  had  to  be  performed, 
and  an  artificial  anus  was  established  in  the  left  groin.  The  patient 
recovered,  but  the  fecal  fistula  remained. 

Bryant  related  the  case  of  a  woman,  aged  seventy-four,  who  had 
been  suffering  from  obstruction  due  to  invagination  for  fourteen  days. 
He  suspected  the  existence  of  a  growth,  and  this,  after  much  diffi- 
culty, was  found,  drawn  down,  and  removed,  the  patient  making  a 
rapid  and  perfect  recovery. 

Barker,  in  a  case  of  invagination  of  the  rectum  due  to  adenoid 
epithelioma  of  that  part  of  the  bowel,  succeeded  in  drawing  down 
and  excising  the  affected  part  and  in  reducing  the  invagination.  The 
patient  recovered  completely.  Three  similar  cases  had  been  treated 
previously  in  the  same  manner,  two  by  Verneuil  and  one  by  Kulen- 
kampff, only  one  of  them  recovering. 

The  case  reported  by  Nicolaysen  is  of  special  interest  as  illus- 
trating the  course  to  be  pursued  when  it  becomes  necessary  to 
resect  a  portion  of  the  intestine  with  the  tumor.  The  patient  was  a 
woman  forty-nine  years  of  age,  who  had  suffered  from  troublesome 
constipation  and  painful  defecation  for  a  year,  due  to  chronic  invagi- 
nation of  the  sigmoid  flexure  of  the  colon  into  the  rectum,  pro- 
duced by  an  epithelioma.  Through  the  rectum  a  tumor  could  be 
felt  that,  by  traction,  could  be  drawn  down  to  the  anus.  The  diag- 
nosis made  was  carcinoma  of  the  colon  and  invagination  of  the  colon 
into  the  rectum.  The  patient  could  produce  the  invagination  at  will. 
The  extirpation  was  made  by  pulling  the  tumor  downward  beyond 
the  anal  orifice.  The  healthy  mucous  surfaces  two  and  one-half 
centimeters  above  the  base  of  the  tumor  were  circumscribed  by  a 
row  of  silk  sutures  that  were  carried  through  the  entire  thickness 
of  both  intestinal  walls.  The  tumor  was  excised  one  centimeter 
below  the  sutures  ;  only  one  artery  had  to  be  tied.  Posteriorly  and 
on  the  left  side  of  the  circular  wound  the  divided  mesocolon  could 
be  seen.  The  wound  was  accurately  united  by  a  superficial  con- 
tinued suture.  As  soon  as  the  bowel  was  replaced  it  retracted  as 
far  as  the  upper  portion  of  the  rectum.  The  patient  recovered 
after  fifteen  days,  and  reported  herself  well  at  the  end  of  two  and  a 


SYMPTOMS    AND    DIAGNOSIS. 


893 


half  months.  Tlie  intestinal  tube  removed  measured  6q  cm 
Lnder  the  microscope  the  tumor  showed  the  typical  structure  of 
cxiindnc-celled  ei)ithelioma. 

Claudot   has   given   an   accurate    description    of  a   specimen    of 
double  invagmation  in  a  patient  who  had  died  with  symptoms  of 
intestinal    obstruction.      The   first   invagination  was   80   cm    below 
the  pylorus,  the  second  two  meters  further  down   the  latter  con 
sisting  of  an  invagination  of  the  ileum  into  the  colon    the  intus 
susceptum  having  advanced  nearly  the  entire  length  of  'the  ascend- 
ing colon.      The  upper  invagination  showed  evidence  of  gan^^rene 
of  which  no  sign  could  be  seen  in  the  lower,  and  for  this  Reason 
It  IS  probable  that  the  upper  invagination  occurred  fir.st      Intestinal 
hemorrhage   was  one  of  the  prominent  symptoms  durin-r    lifc    in 
this  case. 

At  a  meeting  of  the  Pathological  Society  of  London  Power 
demonstrated  a  specimen  of  double  intussusception  obtained  from  a 
child  five  months  old.  One  intussusception,  two  inches  in  lenoth 
was  in  the  ileocecal  region  ;  the  other,  one  inch  in  length  in'the 
transverse  colon.  The  latter  was  an  ascending  invagination  '  Both 
invaginations  showed  adhesions  between  the  serous  surfaces,  and 
consequently  must  have  been  antemortem  conditions. 

Symptoms  and  Diagnosis.— Treves  asserts  that  30  per  cent, 
of  all  forms  of  intestinal  obstruction,  exclusive  of  hernia  and  con- 
genital malformations,  are  cases  of  invagination.     The  same  author 
recognizes  clinically  four  forms.      The  ultra  acute  is  very  rare  and 
terminates  fatally  in  twenty-four  hours;  the  acute,  lasting  from  two 
to  seven  days,  constitutes  about  48  per  cent,  of  all  cases  of  invagi- 
nation ;  the  subacute,  lasting  from  seven  to  thirty  days,  about  34 
per  cent.  ;  and  the  chronic,  la.sting  over  thirty  days,  occurs  about 
eighteen   times  out  of  every   100  cases.      As  far  as  the  ojjerative 
treatment  is  concerned,  it  is  exceedingly  important  to  classify  all  cases 
into  acute  and  chronic,  as  in  the  former  class  the  symptoms  appear 
u  ith  great  violence,  and  the  pathologic  changes  at  the  seat  of  invagi- 
nation  come  on  so  rapidly  that  death  is  inevitable  unless  efficient 
surgical   treatment  is  resorted  to  before  the  tissues  at  the  .seat  of 
invagination  have  undergone  changes  incapable  of  repair.      In  the 
chronic  form  the  .symptoms  are  never  .so  urgent  and  the  adoption 
of  early  radical   measures  is   not   .so  positively  indicated.      Of  the 
anatomic  forn^s  of  the  ca.ses  collected  by  Treves,  30  per  cent,  were 
enteric  ;  18  were  colic  ;  44  were  ileocecal ;  and  8  were  ileoc(;lic.    The 
enteric  forms  are   most  commcm  at  the  lower  part  of  the  jejunum 
and  are  small.       The  colic  forms  are  mo.stiy  to  the  left  of  the  trans- 
verse colon.      The   latter,  as  a  rule,  belong   to   the   chronic  form  of 
invagination. 

Leichtenstern  calls  an  invagination  ileocecal  when  the  ileocecal 
valve  is  pushed  forward  and  forms  the  apex  of  the  intu.ssusceptum, 
and  ileocolic  when  the  ileum  is  pushed  through  the  valve.  The 
invagination  always  increases  at  the  expense  of  the  intussuscipien.s. 


8g4  INVAGINATION. 

In  examining  479  cases  of  invagination  in  reference  to  the  anatomic 
location  of  the  lesion,  he  gives  the  following  figures  : 

Ileocecal 212 

Ileum 142 

Colon 86 

Ileocolic 39 

479 
Symptoms  of  intestinal  obstruction  in  infants  and  children,  unat- 
tended by  fever  during  the  incipiency  of  the  attack,  must  always 
arouse  well-founded  suspicions  of  invagination.  In  adults  and  the 
aged,  vague  intestinal  symptoms  preceding  an  attack  of  intestinal 
obstruction  should  tend  to  call  our  attention  in  the  same  direction. 
Except  in  the  most  acute  forms,  obstruction  from  invagination  dif- 
fers clinically  from  the  other  forms  in  that  the  obstruction  is  seldom 
complete,  the  lumen  of  the  intussusceptum  being  sufficiently  patent 
to  permit  the  passage  of  gas  and  liquid  feces.  Partial  obstruction  is 
a  conspicuous  clinical  feature  of  chronic  invagination.  Unless  the 
obstruction  is  complete,  the  tympanites  is  either  entirely  absent  or, 
at  any  rate,  not  extensive.  The  most  reliable  diagnostic  evidence  of 
invagination  is  a  sausage-shaped  swelling,  which  can  often  be  satis- 
factorily felt  and  outlined  by  palpation  through  the  intact  abdominal 
wall,  or,  if  the  intussusceptum  has  reached  the  rectum,  by  digital 
examination.  The  existence  of  mucus  and  streaks  of  blood  in  the 
scanty  fecal  discharges,  and  the  tenesmus,  if  the  invagination  is  colic, 
are  very  important  symptoms  in  differentiating  invagination  from 
other  forms  of  intestinal  obstruction  and  appendicitis.  Rectal  infla- 
tion of  air  is  a  very  valuable  diagnostic  resource  in  establishing  not 
only  the  existence,  but  also  the  anatomic  location,  of  the  invagina- 
tion. Active  peristalsis  above  the  obstruction  is  a  conspicuous 
symptom  in  the  chronic  variety  of  invagination. 

Pathology  of  Acute  Invagination. — The  pathologic  changes 
in  the  acute  form  of  invagination  are  chiefly  of  two  kinds  :  (i) 
Obstruction  of  the  bowel ;  (2)  strangulation  of  the  intussusceptum. 
Both  of  these  results  may  be  absent  in  the  chronic  form.  The 
obstruction  is  not  only  due  to  the  narrowing  of  the  lumen  of  the 
bowel  by  the  invagination,  but  also  to  the  swelling  of  the  invag- 
inated  portion  caused  by  the  constriction  of  the  blood-vessels  sup- 
plying the  intussusceptum  at  the  neck  of  the  intussuscipiens.  In 
cases  of  chronic  invagination,  where  no  such  vascular  engorgement 
is  present,  the  lumen  of  the  intussusceptum  remains  sufficiently  large 
for  a  free  passage  of  the  intestinal  contents,  and  no  symptoms  of  ob- 
struction are  observed.  In  a  number  of  experiments  on  animals 
where  invagination  was  artificially  produced  no  symptoms  of  obstruc- 
tion were  observed,  and  when  the  animals  were  killed,  weeks  or 
months  after  the  invagination  had  been  made,  the  lumen  of  the  in- 
tussusceptum was  not  larger  than  an  ordinary  lead-pencil,  and  yet 
the  bowel  on  the  proximal  side  was  not  dilated,  but  somewhat  hyper- 
trophic.    The  greatest  danger  after  invagination   has  taken  place 


Plate  7. 


Ileocolic  invafjinatioii,  showinf^  tip  of  appendix  iirojcctiiif^  from  tin-  neck  of  tlie 
intussuscipicns. 


PATHOLOGY  OF  ACUTE  INVAGINATION.  895 

arises  from  the  constriction  of  the  intussusceptum  at  the  neck  of  the 
intussLiscipiens.  The  acuity  of  the  symptoms  is  always  propor- 
tionate to  the  severity  of  the  strangulation  at  this  point.  The  circular 
constriction  interferes  with  the  return  of  venous  blood  from  the  in- 
tnssnsceptutn,  and  is  followed  by  edema,  complete  stasis,  and  gan- 
grene of  the  constricted  portion.  An  acute  invagination  becomes 
irreducible  by  ordinary  means  within  a  few  hours  on  account  of  the 
appearance  of  edema  in  the  intussusceptum.  If  the  strangulation  is 
less  intense,  the  passive  congestion  precedes  a  plastic  inflammation 
of  the  serous  surfaces  held  in  apposition,  and  adhesions  form  that 
again  oppose  or  render  a  reduction  impossible.  In  cases  where  gan- 
grene of  the  invaginated  portion  follows  within  a  few  hours  or  da\'s 
after  the  invagination,  no  adhesions  form  between  the  serous  surfaces. 
Adhesions  at  the  neck  of  the  intussuscipiens  and  throughout  the  ex- 
tent of  the  invagination  may  form  soon,  and  they  may  be  absent  after 
.six  weeks  in  the  chronic  variety.  Adhesions  are  met  with  in  about 
80  per  cent,  of  chronic  cases  and  40  per  cent,  of  acute  ones.  In 
acute  cases  a  fatal  termination  usuallx'  takes  place  from  perforation 
at  the  neck  of  the  intussuscipiens,  followed  by  septic  peritonitis. 
Numerous  cases  have  been  reported  where  a  spontaneous  cure  was 
effected  by  sloughing  and  elimination  of  the  intussusceptum.  This 
favorable  termination  is  pos.sible  only  if  the  continuity  of  the  intestine 
is  restored  at  the  neck  of  the  intussuscipiens  by  firm  unyielding 
adhesions  before  the  proximal  end  of  the  intussusceptum  has  be- 
come gangrenous,  or  if  the  line  of  demarcation  is  below  the  neck. 
Gangrene  usually  commences  at  the  apex  of  the  intussusceptum 
and  travels  in  the  direction  of  the  neck.  That  sloughing  and 
elimination  of  the  intussusceptum  are  not  always  followed  by 
recovery  becomes  evident  from  a  study  of  149  ca.ses  collected  by 
Leichtenstern  where  this  occurred.  Out  of  this  number  61  died 
and  88  recovered,  a  mortality  of  41  per  cent.  Separation  of  the 
gangrenous  intussusceptum  usually  takes  place  in  acute  ca.ses  in 
from  the  eleventh  to  the  twenty-first  day,  and  in  children  somewhat 
earlier  than  in  adults.  The  length  of  the  slough  corresponds  with 
the  length  of  the  invaginated  portion,  and  cases  are  on  record  where 
recovery  followed  after  the  elimination  of  five  or  .six  feet  of  intes- 
tine. According  to  Treves,  spontaneous  elimination  occurs  in 
about  40  per  cent,  of  all  cases.  The  frequency  with  which  it  takes 
place  in  the  different  anatomic  forms  varies,  being  20  per  cent,  in  the 
ileocecal  form,  28  per  cent,  in  the  colic  form,  and  61  per  cent,  in 
the  enteric  form,  so  that  it  is  most  rare  in  the  mostconmion  variety. 
The  frequency  of  elimination  of  the  gangrenous  part  increases  with 
the  age  of  the  patient,  being  least  conmion  in  infants  on  accoimt  of 
the  rapidly  fatal  course  of  the  disea.se  in  them,  and  most  frequent 
in  patients  advanced  in  life. 

Jiirch-Ilirschfcld  gives  an  accurate  postmortem  dcsi  liption  of  a 
child  two  years  of  age  who  had  recovered  fiom  a  double  invagiria- 
tion  by  sloughing  and  elimination  of  the  intussusceptum,  and  died 


896  INVAGINATION. 

four  months  later  of  measles.  At  the  necropsy  it  was  found  that 
the  lower  portion  of  the  ileum,  the  cecum,  and  the  appendix  ver- 
miformis  were  absent.  A  circular  cicatrix  in  the  lumen  of  the  bowel 
showed  where  separation  had  taken  place  ;  upon  the  serous  surface 
at  the  same  point  a  circular  depression  indicated  the  site  where  sepa- 
ration had  occurred.  The  second  invagination  had  evidently  been 
in  the  colon  at  the  junction  of  the  ascending  with  the  transverse 
portion,  as  a  similar  cicatrix  was  also  found  in  this  locality.  The 
cures  after  spontaneous  elimination  of  the  intussusceptum  are  often 
more  apparent  than  real,  as  such  an  ideal  restoration  of  the  intes- 
tinal canal  as  described  by  Birch-Hirschfeld  is  but  rarely  effected. 
Kuettner  has  followed  up  the  history  of  several  of  these  cases,  and 
has  found  that  not  an  inconsiderable  number  of  them  die  later  of 
perforation  and  peritonitis.  Stricture  of  the  intestine  has  also  been 
observed  as  a  sequel  in  some  of  these  cases. 

Gerry  reports  such  a  case.  The  invagination  was  acute,  and  after 
three  weeks  a  portion  of  the  small  intestine  17^  inches  in  length 
passed  per  anum,  followed  later  by  a  number  of  smaller  fragments. 
Soon  after  the  apparent  recovery  had  taken  place  symptoms  of  ob- 
struction again  set  in,  due  to  the  formation  of  a  stricture  at  the  point 
where  spontaneous  resection  had  taken  place.  The  patient  died 
seven  months  after  the  invagination  from  the  effects  of  obstruction. 
At  the  necropsy  a  circular  stricture  was  found  in  the  upper  part  of 
the  small  intestine,  with  loss  of  several  feet  of  the  intestine  by 
sloughing,  a  fistulous  communication  between  the  small  intestine 
and  the  descending  colon,  and  chronic  peritonitis. 

Hassler  relates  a  very  instructive  case  of  intestinal  obstruction 
following  invagination  and  sloughing  of  the  intussusceptum,  which 
occurred  in  the  practice  of  Brahmann.  The  patient  was  a  boy, 
aged  fifteen,  who  suffered  from  acute  invagination  in  March,  1892. 
Four  weeks  after  the  attack  a  piece  of  gangrenous  intestine  was 
discharged  with  the  stool,  the  discharge  being  followed  by  apparent 
recovery.  Two  months  later  symptoms  of  obstruction  returned. 
At  this  time  a  swelling  the  size  of  a  hen's  egg  could  be  felt  in  the 
lower  part  of  the  ileum.  Laparotomy  was  performed.  The  ob- 
struction was  found  at  the  swelling.  By  pressure,  fluid  feces  could 
be  forced  from  the  proximal  into  the  distal  part  of  the  intestine.  The 
opening,  however,  appeared  to  be  small.  As  the  proximal  end  was 
not  in  a  favorable  condition  for  resection  and  suturing,  the  affected 
part  of  the  bowel  was  brought  forward  into  the  wound,  where  it  was 
fastened.  Two  days  later  the  bowel  was  opened  above  the  seat  of 
obstruction.  Two  weeks  subsequently  enterectomy  and  circular 
suturing  were  done.  Recovery  followed  without  any  untoward  symp- 
toms. The  specimen  showed  that  at  the  time  the  resection  was  made 
the  lumen  of  the  bowel  was  completely  obliterated  by  cicatricial 
contraction.  The  swelling  immediately  below  the  stricture  had  the 
shape  and  appearance  of  a  polypus,  but  on  careful  examination  proved 
to  be  the  remnant  of  the  intussusceptum. 


PATHOLOGY    OF    CHRONIC    INVAGINATION.  897 

It  will  be  seen,  from  the  foregoing,  that  very  little  reliance  can 
be  placed  on  nature's  resources  in  reestablishing  the  permeability  of 
the  intestinal  canal  in  invagination,  as  even  in  the  most  favorable 
cases  the  temporary  relief  following  sloughing  of  the  invaginated 
portion  is  so  frequentl\-  followed  by  cicatricial  stenosis  and  flexion. 

Pathology  of  Chronic  Invagination. — In  cases  of  chronic 
invagination  the  symptoms  are  identical  with  those  of  intestinal 
stenosis  from  other  causes.  The  constriction  at  the  neck  of  the 
intussuscipiens  is  not  sufficient  in  degree  to  arrest  the  circulation  in 
the  invaginated  portion,  consequenth^  gangrene  does  not  take  place. 
The  seat  of  the  invagination  and  the  bowel  on  the  proximal  side 
become  the  seat  of  hyperplastic  changes  resulting  from  the  chronic 
congestion  that  attends  the  lesion  and  from  the  increased  peristalsis 
that  is  maintained  by  the  chronic  obstruction.  Adhesions  do  not 
form  with  the  same  rapidity  in  the  subacute  variet}',  and  reduction 
is  often  possible  weeks  and  months  after  the  accident  has  occurred. 
The  chronic  form  of  invagination  is  very  often  caused  by  a  peduncu- 
lated, interstitial,  or  circular  tumor,  in  which  case  the  tumor  always 
forms  the  apex  of  the  intussusceptum.  Sloughing  is  of  rare  occur- 
rence. 

Pohl  has  described  an  interesting  specimen  of  chronic  invagina- 
tion taken  from  a  man  sixty-two  years  of  age  who  suffered  from 
two  attacks  of  intestinal  obstruction  eleven  years  apart.  The  second 
attack  proved  fatal  after  an  illness  of  eleven  days.  The  postmor- 
tem appearances  indicated  that  the  invagination  that  was  found  had 
existed  for  eleven  years,  and  that  the  second  attack  was  due  to  an 
aggravation  of  the  mechanical  difficulties  at  the  seat  of  invagination, 
and  that  had  given  rise  to  ulcerative  inflammation  of  the  mucous 
membrane  lining  the  intussusceptum,  perforation,  and  suppurative 
peritonitis.  The  intussusception  was  located  in  the  lower  portion 
of  the  ileum.  The  intussuscipiens  was  thirty  centimeters  in  length, 
its  muscular  coat  hypertrophic,  the  mucous  membrane  thickened 
and  very  vascular,  and  some  of  its  folds  adherent  to  the  inclosed 
intestine;  on  the  posterior  wall,  near  the  mesenteric  attachment, 
two  perforations  were  found.  The  intussuscei:>tum  was  twenty-four 
centimeters  in  length,  and  its  mucous  membrane  was  extensively 
ulcerated  ;  old  and  firm  adhesions  were  found  at  the  neck  of  the 
intussuscipiens.  The  mesentery  of  the  ileum  throughout,  but  espe- 
cially at  the  seat  of  invagination,  was  much  thickened.  The  ileum 
above  obstruction  was  dilated,  and  its  walls  were  thickened. 

Ixichtenstern  reports  a  case  of  chronic  invagination  that  presents 
a  number  of  interesting  points.  The  attack  was  brought  on  by  indis- 
creet diet,  and  was  attended  by  well-marked  .symptoms,  tenesmus, 
and  liquid  stools  mixed  with  mucus  and  blood.  The  patient  lived 
for  eleven  weeks.  After  the  fir.st  few  days  the  stools  were  normal 
in  size  and  consistence.  Recurring  colicky  i)ains,  often  very  .severe, 
con.stituted  the  mo.st  troublesome  and  important  .symptom.  A  swell- 
ing in  the  region  of  the  transverse  colon  could  always  be  felt,  but 
57 


898  INVAGINATION. 

became  firmer  and  more  circumscribed  during  the  attacks  of  colic  or 
after  a  prolonged  examination  by  palpation.  The  necropsy  revealed 
an  ileocecal  invagination,  the  lowest  portion  of  which  consisted  of 
the  point  of  entrance  of  the  ileum  into  the  colon,  the  inner  cylinder 
of  the  cecum  and  ascending  colon,  and  the  outer  cylinder  or  sheath 
of  the  transverse  colon.  All  the  parts  involved  in  the  invagination 
were  the  seat  of  hypertrophic  changes. 

Treatment. — Invagination  sufficient  in  extent  and  duration  to 
give  rise  to  intestinal  obstruction  is,  from  the  very  beginning,  as 
much  a  surgical  affection  and  requires  as  prompt  surgical  inter- 
ference as  a  strangulated  hernia.  The  physician  must  become 
a  surgeon  or  must  avail  himself  of  the  services  of  one  as  soon  as  a 
diagnosis  can  be  made.  There  is  no  form  of  intestinal  obstruction 
that  offers  a  better  prognosis  than  intussusception  if  rational  surgi- 
cal treatment  is  resorted  to  within  a  few  hours  after  the  accident  has 
occurred  ;  and  no  other  form  is  sooner  followed  by  more  dangerous 
complications  than  acute  invagination.  As  invagination  is  pro- 
duced by  exaggerated  or  irregular  peristalsis,  and  the  descent  of 
the  invaginated  portion  often  takes  place  with  great  rapidity,  the 
first  indication  that  presents  itself  in  the  treatment  is  to  quiet  the 
intestinal  contractions.  This  can  be  done  most  speedily  by  washing 
out  the  stomach,  by  suspending  stomach-feeding,  and  by  adminis- 
tering opium,  preferably  the  resin  or  tincture.  If  the  opiate  can 
not  be  given  by  the  mouth,  it  should  be  administered  by  the  rectum 
or  subcutaneously.  Of  course,  great  caution  is  necessary  in  the 
use  of  this  drug  in  infants  and  young  children.  The  next  step  in 
the  treatment  consists  in  the  employment  of  such  mechanical  meas- 
ures as  are  likely  to  prove  useful  in  effecting  disinvagination  without 
a  formal  operation. 

Early  recognition  of  the  existence  of  invagination  is  of  the  great- 
est importance  for  successful  treatment,  as  the  prospects  for  success- 
ful reduction  by  ordinary  surgical  means  diminish  with  the  develop- 
ment of  secondary  pathologic  conditions  at  the  seat  of  invagination. 
Many  of  the  artificial  invaginations  in  animals  previously  described 
were  reduced  spontaneously  within  a  few  hours,  and  in  order  to 
study  the  effects  of  invagination  it  was  necessary  to  resort  to  sutur- 
ing at  the  neck  of  the  intussuscipiens  in  order  to  retain  perma- 
nently the  invaginated  portion.  Reduction  was  resisted  after  a  time 
either  by  the  swollen,  edematous  intussusceptum  or  by  the  adhe- 
sions at  the  neck  of  the  intussuscipiens,  or  between  the  serous 
surfaces  throughout  the  invaginated  portion  of  the  bowel.  From 
these  observations  we  must  conclude  that  reduction  by  gentle  but 
efficient  distention  of  the  bowel  below  the  invagination  would  suc- 
ceed in  the  majority  of  cases  if  this  procedure  were  practised  before 
either  of  the  two  principal  conditions  that  cause  irreducibility  has 
had  time  to  make  its  appearance.  As  soon  as  the  existence  of 
an  invagination  is  suspected,  the  large  intestines  should  be  emptied 
of  their  contents  by  the  administration  of  a  large  enema,  the  patient 


TREATMENT RECTAL    INSUFFLATION.  899 

being  placed  in  Hegar's  position.  After  this  has  been  done,  the 
patient  should  be  placed  thoroughly  under  the  influence  of  an 
anesthetic,  so  as  to  facilitate  the  next  step  in  the  treatment  by 

Rectal  Insufflation  of  Hydrogen  Gas  or  Air. — As  gas  can  be 
readily  forced  beyond  the  ileocecal  vah'e,  this  method  of  treatment 
is  applicable  in  the  treatment  of  invagination  in  any  portion  of  the 
intestinal  canal,  and  as  distention  of  the  intestine  below  the  seat  of 
obstruction  may  prove  successful  in  correcting  the  mechanical  diffi- 
culties due  to  other  causes,  it  should  be  resorted  to  both  as  a  diag- 
nostic and  therapeutic  measure  in  the  beginning  of  all  cases  of 
intestinal  obstruction  if  a  correct  diagnosis  can  not  be  made  without 
it.  The  modus  operandi  of  this  surgical  resource  was  witnessed  in 
an  animal  on  the  third  day  after  the  invagination  had  been  made,  by 
opening  the  abdomen  and  exposing  to  sight  the  seat  of  invagination 
before  the  insufflation  was  made.  In  this  instance  two  inches  of  the 
ileum  were  invaginated  into  the  colon  and  fixed  by  two  fine  silk 
sutures  at  the  neck  of  the  intussuscipiens.  On  the  third  day  the 
abdominal  cavit}^  was  reopened  by  an  incision  along  the  outer  border 
of  the  right  rectus  muscle,  and  the  invaginated  bowel  drawn  forward 
into  the  wound.  The  bowel  at  point  of  operation  was  very  vascular, 
and  the  neck  of  the  intussuscipiens  was  covered  with  plastic  exuda- 
tion. The  sutures  were  removed,  and  the  rectum  and  colon  were 
distended  with  gas  for  the  purpose  of  effecting  reduction.  As  soon 
as  the  colon  had  become  thoroughly  distended,  the  adhesions  that 
had  formed  gave  way  with  an  audible  noise,  and  complete  reduction 
followed  in  such  a  manner  that  the  part  last  invaginated  was  finst 
released.  As  the  force  necessary  to  rupture  the  adhesions  and  to 
reduce  the  bowel  produced  no  injury  of  any  kind  to  the  intestine 
below  or  at  the  seat  of  invagination,  this  experiment  would  tend  to 
prove  that  insufflation  can  be  practised  successfully  in  cases  of 
invagination  of  several  days'  duration. 

The  rectal  insufflation  of  hydrogen  gas  or  air  in  the  reduction  of 
an  invagination  should  always  be  made  under  the  influence  of  an 
anesthetic  administered  to  the  extent  of  complete  muscular  relaxa- 
tion. The  pressure  upon  the  rubber  balloon  should  be  uninter- 
rupted, and  should  never  exceed  two  pounds  to  the  square  inch. 
Di.sinvagination  is  effected  by  inflation  by  two  distinct  forces.  In 
the  first  place,  the  steady  clastic  pressure  of  the  gas  distends  the 
bowel  between  the  sheath  and  the  returning  cylinder,  which  makes 
traction  upon  the  neck  of  the  intu.ssuscipiens,  while  the  column  of 
gas,  by  its  pressure  against  the  apex  of  the  intu.ssusceptum,  acts  as 
a  direct  reduction  force.  In  order  to  accomplish  the  desireil 
mechanical  effect,  the  inflation  mu.st  be  made  slowly  and  continu- 
ously, as  when  this  is  done  there  is  less  danger  of  rupturing  the 
bowel  than  when  rapid  inflation  is  made  under  the  .same  pressure, 
but  with  interruptifjns.  and  the  object  of  the  inflaticjii  is  more  surely 
realizcfl.  The  return  of  the  gas  is  prevented  most  effectually  by  an 
assistant  pressing  the  margins  of  the  anus  against  the  rectal  tube. 


900  INVAGINATION. 

A  small  female  gutta-percha  syringe  makes  the  best  rectal  tube.  A 
sudden  diminution  of  pressure  indicates  either  that  disinvagination 
has  been  effected  or  that  a  rupture  of  the  intestine  has  occurred.  It 
is  exceedingly  important  that  the  surgeon  should  satisfy  himself  of 
the  existence  of  a  rupture  if  this  accident  has  occurred.  The  best 
way  to  recognize  the  accident  is  to  continue  the  inflation  under  a 
pressure  of  not  more  than  a  quarter  to  half  a  pound  to  the  square 
inch.  If  the  invagination  has  been  reduced,  the  intestine  above  it 
will  become  gradually  distended  by  the  gas,  and  the  distention  of 
the  abdomen  takes  place  first  over  the  middle  of  the  abdomen  and 
above  the  pubes,  ascending  gradually  as  the  inflation  is  continued 
in  an  upward  direction.  If  the  intestine  has  been  ruptured,  the  gas 
escapes  into  the  peritoneal  cavity,  and  the  existence  of  the  accident 
is  proved  by  the  appearance  of  a  uniform  free  tympanites,  with  dis- 
appearance of  liver  dullness.  In  a  recent  case  there  is  no  danger 
of  rupturing  the  bowel  under  a  pressure  of  two  pounds  to  the 
square  inch,  and  in  cases  where  the  tissue  of  the  intestine  yields 
under  this  pressure,  a  laparotomy  is  the  only  proper  remedy,  and 
the  occurrence  of  the  accident  renders  the  indication  for  the  per- 
formance of  the  operation  imperative  without  adding  materially  to 
its  danger. 

Massage. — It  is  very  natural  that  massage  should  have  had  a 
limited  trial  in  attempts  to  reduce  invagination.  Herder  reports  two 
cases  successfully  treated  by  this  procedure.  Both  patients  were 
infants,  one  fourteen  days  old  and  the  other  eight  months  old.  In 
one  the  invagination  reached  the  splenic  flexure  of  the  colon  ;  in  the 
other  the  intussusceptum  had  advanced  as  far  as  the  sigmoid  flex- 
ure. The  manipulations  consisted  of  inserting  the  little  finger  of  the 
left  hand  into  the  rectum,  and  placing  the  middle  finger  of  the  other 
hand  upon  the  abdominal  wall,  at  a  point  that  would  bring  the  in- 
vaginated  portion  between  both  fingers.  Pressure  was  made  from 
left  to  right,  and  the  swelling,  which  could  be  distinctly  felt,  was 
reduced  in  size.  Repetition  of  the  procedure  at  different  times 
finally  resulted  in  disinvagination  and  recovery.  Marie  succeeded 
in  reducing  the  invagination  in  a  third  case  by  limiting  the  manipu- 
lations to  the  outside  of  the  abdominal  Avail.  External  massage 
may  prove  useful  in  aiding  rectal  insufflation  in  the  reduction  of 
recent  invaginations,  and  in  such  cases  deserves  a  trial. 

Colostomy. — Two  indications  for  colostomy  might  arise  in  the 
treatment  of  colic  invagination  :  (i)  In  acute  cases,  when  the  gen- 
eral symptoms  are  so  grave  as  to  contraindicate  a  laparotomy.  (2) 
In  irreducible  chronic  cases,  when  the  lower  portion  of  the  colon  is 
invaginated  into  the  upper  part  of  the  rectum,  where  it  is  impos- 
sible to  make  a  resection  or  anastomosis  by  lateral  apposition. 
According  to  the  location  of  the  invagination,  the  operation  is  made 
m  either  the  right  or  the  left  iliac  region,  in  the  former  instance  the 
opening  being  made  in  the  cecum,  and  in  the  latter,  in  the  descend- 
ing colon. 


LAPAROTOMY, 


901 


Dubois  reports  a  case  of  intussusception  where  the  invaginated 
portion  could  be  felt  in  the  region  of  the  sigmoid  flexure,  through 
the  abdominal  wall.  Colostomy  was  performed  above  the  seat  of  ob- 
struction, and  the  patient  not  only  recovered,  but  four  months  later 
the  permeability  of  the  intestinal  canal  was  restored  spontaneously, 
but  the  artificial  opening  had  not  closed. 

A  case  of  chronic  invagination  of  the  colon  complicated  by  a 
circular  carcinoma  below  the  sigmoid  flexure  recently  came  under 
my  observation.  When  the  patient  was  admitted  into  the  hospital, 
the  obstruction  was  complete.  The  abdomen  was  enormously  dis- 
tended, and  the  apex  of  the  intussusceptum  could  be  felt  very  dis- 
tinctly a  few  inches  above  the  anus,  presenting  a  hard,  nodular 
mass,  with  an  opening  not  large  enough  to  permit  the  insertion  of 
the  tip  of  the  index-finger.  The  patient's  general  condition  was 
critical,  hence  no  effort  was  made  to  correct  or  remove  the  invag- 
ination. A  left  inguinal  colostomy  afforded  prompt  relief  Spon- 
taneous reduction  of  the  invagination  commenced  soon  after  the 
operation,  and  was  completed  two  weeks  later. 

Enterostomy. — In  irreducible  iliac  and  ileocecal  invagination  an 
enterostomy  should  be  made  only  when  the  patient  is  in  such  a  col- 
lapsed condition  that  more  radical  measures  are  inadmissible.  As 
in  the  majority  of  cases  the  invagination  is  below  the  ileocecal  valve, 
the  artificial  opening  should  be  made  in  the  right  iliac  region. 
Should  the  invagination  be  located  higher  up  in  the  intestinal  canal 
and  an  empty  collapsed  coil  of  intestine  present  itself  in  the  open- 
ing, it  should  be  pushed  aside  and  search  made  for  a  distended  loop. 
An  enterostomy  is  justifiable  even  when  the  patient  is  in  an  almost 
pulseless  condition,  as  this  operation  is  attended  by  little,  if  any, 
shock,  and  can  be  done  in  a  few  minutes  and,  if  necessary,  without 
an  anesthetic.  Emptying  the  bowel  above  the  seat  of  obstruction 
will  bring  relief  by  removing  the  abdominal  distention  and  by  favor- 
ably influencing  the  invaginated  part  by  diminishing  the  hydro.static 
pressure  above  the  obstruction,  which  is  in  itself  a  potent  means  of 
maintaining  vascular  engorgement. 

Langenbeck  .saved  the  life  of  a  patient  suffering  from  invagina- 
tion of  the  colon  by  an  entero.stomy.  The  invagination  hat!  advanced 
so  far  that  the  apex  of  the  intussusceptum  could  be  felt  in  the  rec- 
tum. Me  performed  Nelaton's  operation,  and  the  patient  recov- 
ered. Nine  montiis  after  the  operation  both  the  invagination  and 
the  artificial  anus  remained. 

Laparotomy. —  Remembering  that  the  general  mortality  of 
invagination  is  70  per  cent.,  and  in  children  less  than  eleven  years 
of  age  .spontaneous  cure  by  elinnnation  of  intussu.sccptum  docs  not 
exceed  12  per  cent.,  it  becomes  plain  that  in  cases  where  reducti()n 
is  not  accomplished  by  rectal  inflatifju  a  lajKirotomy  is  indicated  in 
all  in.stances  where  the  general  condition  of  the  patient  is  such  as  to 
justify  active  procedure.  It  is  true  that  the  experience  of  the  past 
in   the  r.pcrativc  treatment  of  invagination   is  not  such  as  to  inspire 


902  INVAGINATION. 

confidence,  but  it  must  not  be  forgotten  that  almost  without  excep- 
tion the  abdomen  was  opened  only  as  a  last  resort  after  the  patient 
had  been  completely  prostrated  by  the  disease  or  after  the  invagina- 
tion had  given  rise  to  irreparable  local  conditions.  Instead  of  discour- 
aging operative  interference,  the  statistics  collected  so  far  furnish  the 
best  possible  argument  in  favor  of  early  operations  where  simpler 
measures  have  failed. 

Ashurst  brought  together,  with  more  or  less  detail,  the  histories 
of  1 3  cases  in  which  laparotomy  had  been  undertaken  for  the  relief 
of  intussusception.  Of  this  number  5  recovered  and  8  died.  As 
the  result  of  a  study  of  his  cases,  he  arrived  at  the  conclusion 
that  the  operation  is  not  admissible  in  patients  less  than  one  year  of 
age,  as  all  operations  to  that  date  done  in  children  less  than  a  year 
of  age  proved  fatal.  He  also  advises  against  an  operation  when  the 
symptoms  present,  and  particularly  the  existence  of  intestinal  hem- 
orrhage, render  it  probable  that  the  tightness  of  the  intussusception 
will  lead  to  sloughing  of  the  invaginated  portion,  as  he  claims  that 
under  these  circumstances  an  operation  would  almost  surely  fail, 
while  there  is  a  fair  hope  that  separation  of  the  invaginated  mass 
may  lead  to  spontaneous  recovery.  Experience  has  shown  that  a 
cure  by  spontaneous  elimination  of  the  intussusception  seldom,  if 
ever,  takes  place  in  very  young  children  and  infants  ;  consequently 
the  hopelessness  of  the  situation  in  such  cases  where  legitimate 
efforts  at  reduction  have  failed  can  be  advanced  as  the  most  logical 
reason  in  favor  of  operative  treatment,  as  the  patient  and  surgeon 
have  nothing  to  lose  and  everything  to  gain. 

Knaggs,  after  reporting  an  unsuccessful  case  of  abdominal  sec- 
tion for  invagination  that  occurred  in  his  own  practice,  gives  the 
results  of  37  operations,  including  his  own.  Of  this  number  8 
recovered  and  29  died.  In  many  of  these  cases  peritonitis  had  set 
in  before  the  operation  was  performed,  and  this  condition,  and  not 
the  operation,  was  answerable  for  the  subsequent  fatal  issue. 

Sands  tabulated  the  records  of  21  cases  of  laparotomy  for 
intussusception,  8  of  which  have  occurred  since  the  publication  of 
Ashurst's  paper.  Of  20  cases  in  which  the  result  of  the  operation 
is  given,  7  recovered  and  13  proved  fatal,  thus  showing  a  mortality 
of  65  per  cent.  After  a  study  of  these  cases  he  came  to  the  con- 
clusion that  the  prognosis  after  operation  is  also  influenced  by  the  age 
of  the  patient:  thus,  of  12  cases  of  two  years  old  or  under,  3 
recovered  and  9  died.  Of  7  cases  sixteen  years  old  or  over,  4 
recovered  and  3  died,  showing  that  the  mortality  is  greater  in  infants 
than  in  adults.  Sands  remarks,  very  properly,  that  the  mortality 
depends  more  on  the  condition  of  the  intestine  than  on  the  age  of 
the  patient.  In  taking  all  cases  together  he  has  found  that  the  mor- 
tality of  the  operation  is  14  per  cent,  in  the  easy  cases,  and  91  per 
cent,  in  the  difficult  ones. 

The  largest  number  of  operations  for  invagination  has  been  col- 
lected by  Braun.      He  tabulated  51  operations  that  were  performed 


LAPAROTOMY. 


903 


since  1870 — that  is,  operations  done  under  antiseptic  precautions. 
Of  this  number,  1 1  patients  were  cured  and  40  died.  In  27  of 
these  cases  disinvagination  was  effected,  and  in  24  it  was  not ;  of 
the  former,  18  were  children  and  9  were  adults.  Four  children 
recovered,  while  14  died.  Seven  adults  lived  and  2  died.  Resec- 
tion of  the  invaginated  portion  was  practised  1 2  times,  with  only  i 
recovery.  An  artificial  anus  was  established  in  9  ca.ses,  followed 
by  death  in  ever}'  instance. 

Treves  gives  the  general  mortality  in  133  recorded  ca.ses  as  72  per 
cent. ;  when  reduction  was  easy,  it  was  30  per  cent.,  and  wiien  difficult, 
91  per  cent.  No  one  can  look  over  these  tables  without  noticing  that 
the  mortality  was  greatly  influenced  by  the  local  conditions,  as  when 
the  reduction  was  easy  it  was  greatly  lowered.  This  fact  alone 
should  convince  us  that  laparotomy  should  be  resorted  to  without 
delay  as  soon  as  a  faithful  attempt  at  reduction  by  rectal  insufflation 
has  demonstrated  that  reduction  can  not  be  accomplished  in  any 
other  way.  The  operation  should  be  done  as  a  first,  and  not  as  a 
last,  resort.  As  in  cases  of  strangulated  hernia,  the  obstacles  to 
reduction  become  more  persistent  as  time  advances,  and  the  danger 
is  augmented  in  proportion  to  the  time  that  elapses  until  reduction 
is  attempted.  In  reference  to  the  time  when  the  operation  should 
be  done,  a  protest  must  be  entered  against  unnecessary  delay  and 
the  positive  statement  be  made  that  it  should  be  done  as  soon  as  it 
has  been  shown  that  reposition  can  not  be  effected  by  rectal  insuffla- 
tion. The  age  of  the  patient  should  not  enter  into  consideration  in 
deciding  upon  the  propriety  of  an  operation.  Sands  operated  suc- 
cessfully upon  an  infant  only  six  months  of  age,  where  the  ordinary 
treatment  by  injection  and  inflation  had  been  only  partially  effective 
in  accomplishing  disinvagination.  The  cecum  and  ai)pendi.x  vermi- 
formis  and  a  small  portion  of  the  ileum  remained  firmly  fi.xed  in 
the  sheath,  and  it  required  considerable  traction  force  to  release 
them. 

As  could  be  expected,  recent  statistics  place  abdominal  section 
in  the  treatment  of  invagination  in  a  much  more  favorable  light 
than  heretofore.  In  1895  Rydygier  rei)orted  75  abtlominal  .sections 
for  invagination,  which  material  embraced  all  of  the  ca.ses  since 
Braun's  statistics,  and  extended  over  a  period  of  twenty  years, — 
from  1875  to  1895, — with  a  mortality  of  75  per  cent,  in  acute  cases 
and  25.9  per  cent,  in  chrome  cases.  A  year  later  the  statistics 
gathered  by  F.  11.  Wiggin  showed  a  mortality  of  only  22  per  cent. 
In  1897  C.  L.  Gibson  published  the  results  of  treatment  and  nior- 
tility  of  239  cases  of  acute  intussusception,  in  which  the  mortality 
was  estimated  at  53  per  cent.  His  tabK.-s  are  extremely  valuable  in 
showing  the  influence  of  time  in  determining  the  result  ol  operative 
interference.      He  says  : 

"The  mortality,  according  as  the  condition  was  found  to  be 
reducible  or  otherwi.sc,  is  in  direct  proportir)n  to  the  duration  of 
symptoms.     Of  99  reducible  ca.ses,  38   died,  a  mortality  of  38  {)cr 


904 


INVAGINATION. 


cent,  while  in  the  remaining  50  cases,  in  which  reduction  could  not 
be  performed,  the  mortality  was  82  per  cent.,  or  more  than  double. 
As  table  IV  shows  how  the  proportion  of  nonreducible  cases  rose 
steadily  after  the  first  day,  it  requires  no  further  demonstration  that 
an  early  intervention  is  necessary  for  reduction  and  cure  of  the  intus- 
susception by  virtue  of  its  being  reducible." 

Recent  results  seem  to  indicate  that  timely  surgical  interference 
will  bring  invagination — the  form  of  intestinal  obstruction  that  has 
destroyed  more  lives  than  all  the  other  varieties  combined — within 
the  reach  of  successful  treatment  with  results  on  a  level  with  those 
we  now  achieve  in  strangulated  hernia. 

The  incision,  without  exception,  should  be  made  in  the  median 
line,  as  it  furnishes  the  most  ready  access  to  the  invagination, 
and  enables  the  operator  to  apply  the  various  surgical  resources 
with    the    greatest    facility.        For    special    indications    a    lateral 

incision  can  be  made 
later.  If  the  swelling 
has  not  been  previously 
located  by  palpation  or 
insufflation,  it  is  usually 
not  difficult  to  find  the 
seat  of  obstruction.  As 
soon  as  the  invaginated 
part  has  been  found,  it 
should  be  brought  into 
or  as  near  to  the  wound 
as  possible  for  careful  ex- 
amination, as  the  future 
action  of  the  surgeon  will 
be  guided  by  the  local 
conditions  of  the  invagin- 
ated bowel.  If,  on  ex- 
amination, no  evidences 
of  gangrene  are  found, 
efforts  should  be  made 
to  effect  reduction. 
Disinvagination. — In  recent  and  especially  acute  cases,  the 
difficulties  that  resist  reduction  are  not  to  be  sought  in  the  presence 
of  adhesions  as  often  as  in  the  swollen  edematous  intussiisceptinn. 
The  same  measures  should  be  used  to  facilitate  reduction  as  in 
the  preliminary  treatment  of  a  phimosis  or  paraphimosis.  The 
edema  and  inflammatory  swelling  should  be  removed  before  any  efforts 
at  reduction  are  made:  This  can  be  readily  accomplished  by  steady 
and  uninterrupted  manual  compression  of  the  invaginated  portion. 
As  soon  as  the  swelling  has  been  reduced  in  this  manner,  reduction 
is  attempted  by  making  gentle  traction  upon  the  bowel  above  the 
neck  of  the  intussuscipiens  (Fig.  522),  aiding  the  reduction  by  grasp- 
ing the  bowel  below  firmly  with  the  left  hand,  and  pressing  against  the 


Fig.  522. — Senn's  method  of  performing  taxis  in 
reducing  an  invagination. 


INTESTINAL    ANASTOMOSIS.  9O5 

apex  of  the  intussusceptum.  Should  this  fail, inflation  is  practised,  and 
as  soon  as  the  bowel  between  the  returning  cylinder  and  the  sheath 
has  become  expanded,  taxis  is  repeated  in  the  same  manner.  If  this 
manoeuver  fails  to  effect  reduction,  Rydygier  directs  that  reduction 
should  be  facilitated  by  inserting  the  finger  between  the  intussus- 
ceptum and  the  intussuscipiens,  for  the  purpose  of  breaking  up 
adhesions.  Any  one  who  has  had  much  experience  with  such  cases 
must  have  observed  that  the  neck  of  the  intussuscipiens  grasps  the 
bowel  very  tightly,  and  that  any  such  efforts  as  the  introduction  of 
a  finger  would  be  almost  certain  to  result  in  rupture  of  the  bowel. 
If  the  treatment  as  just  directed  does  not  effect  reduction,  the  pres- 
ence of  adhesions  must  be  suspected.  These  should  be  broken  up 
not  by  the  introduction  of  the  finger,  but  by  inserting  and  passing 
around  the  bowel  a  Kocher's  director  or  a  small  probe.  When  the 
adhesions  have  been  severed,  the  efforts  at  reduction  by  traction, 
pressure,  and  inflation  are  repeated. 

Roser  has  suggested  that  after  reduction  has  been  effected  the 
invaginated  portion  should  be  sutured  to  the  abdominal  wall,  for  the 
purpose  of  preventing  reinvagination.  Under  proper  treatment  it  is 
not  very  likely  that  reinvagination  will  take  place,  and  such  fixation 
might  subsequently  result  in  another  form  of  intestinal  obstruction. 
Reinvagination  can  positi\'ely  be  prevented  by  shortening  the 
mesentery  at  the  point  of  invagination  by  folding  it  upon  itself  in  a 
direction  parallel  to  the  bowel,  and  maintaining  it  in  this  position  by 
a  few  catgut  sutures. 

Should  the  bowel  present  any  indications  of  seriously  impaired 
nutrition,  it  must  be  fastened  in  the  wound  with  strips  of  iodoform 
gauze,  until  time  has  decided  upon  the  safety  of  its  replacement  into 
the  abdominal  cavity,  when  the  external  incision  can  be  closed  by 
secondary  suturing. 

Intestinal  Anastomosis. — In  1887  I  recommended  intestinal 
anastomosis  in  cases  in  which  the  invagination  is  irreducible,  and 
claimed  at  that  time  that  upon  relieving  the  obstruction  the  patho- 
logic conditions  that  so  constantly  threaten  life  would  recede.  This 
method  of  dealing  with  the  invagination  must,  of  course,  be  limited 
to  ca.ses  in  which  there  arc  no  indications  of  gangrene  or  perfora- 
tion. 

.Should  repeated  attempts  at  reduction  fail,  one  of  two  courses 
of  treatment  may  be  pursued :  ( i)  The  establishment  of  an  intestinal 
anastomosis  ;  (2)  resection  of  the  invaginated  portion  with  or  with- 
out circular  enterorrhaphy.  Resection  of  the  invaginated  portion, 
especially  if  the  invagination  is  extensive,  is  a  very  grave  undertak- 
ing, as  it  involves  the  removal  of  important  parts  and  requires  a  long 
time  for  its  execution,  a  matter  of  vital  importance  in  these  cases  ; 
on  these  accounts  it  should  never  be  resorted  to  unless  the  invagi- 
nated parts  show  cvi(k:nces  of  gangrene. 

An  intestinal  anastomosis  between  tlie  bowel  above  and  below 
the  invagination  by  suturing,  Murpiiy  button,  or  decalcified  [)erf()r- 


go6 


INVAGINATION. 


ated  bone  discs  can  be  made  in  a  short  time,  and  at  once  restores 
the  continuity  of  the  intestinal  canal.  As  soon  as  the  hydrostatic 
pressure  above  the  obstruction  has  been  removed  by  this  operation, 
the  danger  of  gangrene  is  diminished,  and  the  bowel  may  again  be- 
come permeable  by  a  subsequent  spontaneous  reduction  or  by  elim- 
ination of  the  intussusceptum.  If  the  invagination  remain  perma- 
nently, it  does  no  particular  harm,  as  the  obstructed  portion  has  been 
excluded  by  the  anastomosis  and  subsequently  undergoes  atrophic 
changes.  In  cases  where  the  intussusceptum  has  advanced  beyond 
the  sigmoid  flexure,  it  would  become  necessary,  after  ligation,  to 


Fig-  523- — Bayer's  case  of  irreducible  ileocolic  invagination  successfully  treated  by  ileo- 

colostomy. 

remove  a  part  of  it  through  the  lower  incision,  in  order  to  render 
the  bowel  permeable  below  this  point.  I  have  demonstrated,  to  my 
entire  satisfaction,  the  therapeutic  value  of  this  operation  on  the 
lower  animals. 

Korcynski  reports  an  exceedingly  interesting  case  where  intes- 
tinal anastomosis  was  established  spontaneously  in  a  case  of  invag- 
ination, followed  by  a  cure.  The  patient  was  forty-one  years  of 
age,  and  the  symptoms  of  obstruction  had  lasted  for  six  weeks,  but 
were  completely  relieved  by  the  new  opening.  The  existence  of 
such  an  opening  could  readily  be  verified  by  digital  exploration  of 
the  rectum.     After  the  symptoms  of  obstruction  had  subsided,  the 


TOTAL    RESECTION.  qq- 

exclusion  of  a  part  of  the  intestinal  tract  could  be  ascertained  bv 
nisufflation  of  the  rectum,  which  at  once  produced  a  tympanitic  dis- 
tention of  the  middle  of  the  abdomen  without  distention  of  the  colon 
A  similar  but  small  communication  was  found  on  postmortem  as  in 
the  case  reported  by  Gerry,  previously  referred  to. 

Two  successful  cases  of  intestinal  anastomosis  for  irreducible 
invagination  have  recently  been  reported.  Both  operations  were 
performed  in  1893.  H.  Braun  treated  a  case  of  chronic  ileocecal 
invagination  successfully  by  making  an  ileocolostomy.  The  patient 
was  a  man  who  had  suffered  for  several  months  with  symptoms  of 
chronic  obstruction.  More  than  twenty  centimeters  of  the  ileum 
were  tound  invaginated  into  the  colon.  An  anastomosis  was  estab- 
lished between  the  ileum  above  the  obstruction  and  the  transverse 
colon.  The  patient  recovered,  and  although  the  invagination  re- 
mained, it  caused  no  further  difficulty. 

The  second  case  is  reported  by  C.  Bayer  (Fig.  523),  of  Prague 
who  made  an  ileocolostomy  in  a  case  of  irreducible  ileocolic  invagi- 
nation. The  patient  was  a  girl,  eight  years  old,  and  the  invagina- 
tion was  of  a  subacute  nature.  In  making  the  anastomosis  he 
transversely  incised  the  colon  below,  and  the  ileum  above,  the 
obstruction,  for  a  distance  of  3^^  cm.,  as  is  shown  in  the  illustra- 
tion. The  recovery  was  somewhat  retarded  by  the  formation  of  a 
mural  abscess. 

Extra=abdominaI  Treatment  of  Invaginated  Portion. In  irre- 
ducible invagination  with  indications  of  gangrene,  and  when  the 
patient's  condition  does  not  warrant  total  resection,  the  best  course 
to  pursue  is  to  bring  the  invaginated  portion  into  the  abdominal 
mcision,  fasten  it  in  po.sition  with  a  few  catgut  sutures  and  strips  of 
iodoform  gauze,  and  open  the  bowel  above  the  obstruction,  cither 
at  once  or  one  or  two  days  later.  Should  the  patient  recover, 
secondary  resection  and  circular  entcrorrhaphy  can  be  done  later 
with  a  fair  prosjiect  of  success. 

Total  Resection. — The  only  indication  for  total  resection  of  the 
invagination  is  furnished  by  gangrene,  provided  the  general  condi- 
tion of  the  patient  is  such  as  to  warrant  the  performance  of  .so  grave 
an  operation.  The  extent  of  the  gangrene  is  immaterial  in  refer- 
ence to  the  advisability  of  making  a  resection,  as  a  small  gangren- 
ous spot  neces-sarily  would  leatl  to  perforation  and  death  fiom  septic 
peritonitis  unless  this  radical  measure  is  adopted.  The  resection 
mu.st  always  include  the  entire  intussu.sceptum,  but  not  nece.s.sarily 
the  entire  sheath.  The  first  evidences  of  gangrene  upon  the  exter- 
nal surface  of  the  bowel  appear  about  the  neck  of  the  intu.ssus- 
cipiens  ;  and  when  the  invagination  is  cxten.sive  and  the  lower  portion 
of  the  sheath  presents  a  healthy  appearance,  it  is  necessary  only  to 
resect  the  neck  of  the  intussuscipiens,  and  the  intussiiscepliim, 
which,  after  division  and  isolation  about  the  neck,  can  be  drawn  out 
and  removed.  The  bowel  above  and  below  the  proposed  points  of 
.section  should  be  tied  with  a  rubber  band  to  prevent  fecal  e.xtrava- 


9o8 


INVAGINATION. 


sation  during  the  operation.  The  mesenteric  attachments  must  be 
tied  in  small  sections  with  fine  silk  hgatures,  as  tying  in  larger  sec- 
tions or  with  catgut  is  liable  to  be  followed  by  hemorrhage.  After 
the  resection  has  been  made,  it  becomes  a  serious  question  how  to 
proceed  further.  Shall  the  continuity  of  the  intestinal  canal  be 
restored  at  once  by  suturing,  or  shall  an  artificial  anus  be  estab- 
lished ?  When  the  resection  involves  the  ileum  above  and  the 
colon  below,  it  is  exceedingly  difficult  to  restore  the  continuity  of 
the  intestinal  canal  by  circular  enterorrhaphy  on  account  of  the 
difference  in  the  lumina  of  the  bowel  to  be  united.  As  ileocecal 
invagination  is  the  most  common  form,  it  is  evident  that,  as  a  rule, 
some  other  plan  must  be  followed.  Under  these  circumstances  one 
of  two  methods  of  procedure  can  be  chosen.  The  colon  at  the 
point  of  division  is  inverted  to  the  extent  of  an  inch  or  more,  and 
closed  by  making  a  few  stitches  of  the  continued  suture,  which 
should  embrace  only  the  serous  and  muscular  coats,  and  the  iliac 

end  is  implanted  into  a  slit,  corre- 
sponding in  size  to  the  circumference 
of  the  bowel,  made  in  the  colon  on 
the  side  opposite  to  the  mesocolon, 
at  a  point  just  below  the  closed  end. 
Fixation  is  most  effectually  secured 
by  a  rubber  ring  and  two  inversion 
sutures,  as  described  in  the  section 
on  Lateral  Implantation,  to  which 
should  be  added,  as  a  matter  of  pre- 
caution, a  superficial  continued  su- 
ture. If  lateral  implantation  can  not 
readily  be  done,  an  equally  efficient 
method  consists  in  closing  both  ends 
and  establishing  the  continuity  of 
the  intestinal  canal  by  lateral  apposition,  in  the  same  manner  as 
has  been  described  under  the  head  of  Intestinal  Anastomosis. 
Restoration  of  the  continuity  of  the  intestinal  canal  after  resection 
of  an  invaginated  bowel  by  lateral  implantation  or  lateral  apposition 
requires  much  less  time  than  a  circular  enterorrhaphy,  and  both 
operations  secure  better  conditions  for  definitive  healing  than  circular 
enterorrhaphy  ;  on  these  accounts,  therefore,  they  should,  under 
these  and  similar  circumstances,  be  preferred  to  the  latter  procedure. 
In  cases  of  colic  invagination  requiring  an  extensive  resection, 
approximation  of  the  two  ends  is  not  possible  on  account  of  the 
distance  they  are  separated  from  each  other  and  the  comparatively 
slight  immobility  of  this  part  of  the  intestine.  In  such  a  case 
lateral  implantation  is  impracticable  for  the  same  reasons.  The 
choice  lies  between  lateral  apposition  and  the  establishment  of  an 
artificial  anus  ;  the  latter  should  never  be  made,  as  in  case  of 
recovery  of  the  patient  the  fecal  fistula  would  remain  as  a  perma- 
nent condition   without  any  prospects   of  an   ultimate  cure.     The 


Fig.   524. — Lateral  implantation 

(McCosh). 


RESECTION-    OF    INTUSSUSCEPTUM.  OOQ 

continuity  Of  the  intestinal  canal  can  be  restored  at  once  m  these 
cases  by  makmg  an  ileocolostomy,  or  a  colocolostomy  by  lateral 
apposition,  according  to  the  location  or  extent  of  the  resection 

Wassiljew  reports  a  very  interesting  case  of  resection  for  inva^^i- 
nation  that  ultimately  terminated  in  recovery.      The  patient  wash's 
man,  aged  twenty-five  years,  who  was  seized  with  abdominal  pain 
and  vomiting.      As  the  s^-mptoms  of  obstruction   did  not  yield  to 
ordmar>-  treatment,  laparotomy  was  performed  on  the  second  dav 
On  opening  the  abdominal  cavity  a  swelling  was  readily  detected  in 
the  right  h)-pogastric  region.     This  swelling  was   drawn  forward 
and  was  found  to  be  an  extensive  invagination  of  the  ileum  into  the 
colon.      As  reduction  could  not  be  accomplished,  an  elastic  ligature 
was  tied  around  the  bowel  in  two  places,  and  the  ileum  and  mesen- 
tery were  divided.      Then  the  invaginated  portion  was  readily  with- 
drawn, and  about  seventeen  inches  were  resected.      The  abdominal 
cavity  was  washed  with  a  solution   of  sublimate,  and  the  cut  ends 
ot  the  bowel  were  fixed  by  sutures  to  the  abdominal  wound       Much 
gas  and  fecal  matter  escaped  when  the  ligatures  were  united      Dur- 
ing the  sixth  week  an  operation  was  performed  for  the  cure  of  the 
artificial  anus.     About  six  inches  more  of  the  intestine  were  resected 
and  the  cut  ends  united  by  Czerny's  suture.      On  the  third  day  the 
bouels  moxed,  but  on  the  fifth  day  tiie  fecal  discharges  again  escaped 
through  the  wound.     The  different  attempts  to  close  the  fistulous 
opening  failed.      Digital  exploration  showed  that  a  spur  was  begin- 
ning to  form.      To  this  spur  a  pressure  forceps  was  applied  ■  it^'fell 
off  on  the  third  day.     Ultimately  the  fistula  closed. 

Resection  of  Intussusceptum.— In  1891  I  proposed  resection  of 
the  intussusceptum  as  a  substitute  for  total  resection  in  cases  of  irre- 
ducible invagination  in  which  the  intussuscipiens  was  found  in  a  con- 
dition warranting  such  an  attempt.  The  following  method  was  rec- 
ommended :  Incise  the  intu.ssuscipicns  longitudinally  over  the  convex 
side,  two  inches  or  more  from  the  neck,  and  to  a  sufficient  extent  to 
give  easy  access  to  the  intussusceptum  near  the  neck.  Ligate  the 
intussusceptum  here  with  a  strong  rubber  cord,  amputate  at  a  safe 
distance  below,  and  extract  through  incisions.  Make  a  similar  visceral 
incision  in  the  bowel  above  the  neck,  and  establish  an  anastomosis 
by  uniting  the  incisions  by  suturing.  Murphy  button,  or  decalcified 
bone-plates.  Di.sinvagination  of  the  .stump  is  impo.s.sible  if  the  rub- 
ber ligature  is  tied  with  sufficient  firmness,  and  the  ccmtinuity  of  the 
intestinal  canal  is  at  once  restored  b)'  the  anastomosis,  hy  the 
time  the  ligature  cuts  its  way  through  the  tissues,  the  .serous  sur- 
faces will  have  become  firmly  united. 

In  1892  Harkcr  devised  what  he  considered  a  new  operation, 
calculated  to  obviate  the  necessity  of  resecting  the  intu.ssuscipicns 
in  cases  of  irreducible  invagination.  He  places  a  ring  of  sutu'cs 
around  the  neck,  so  as  to  fasten  together  the  intussuscij)iens  and 
intussuscej)tiim  ;  then  he  incises  the  former,  generally  longitudinally. 
Ihrough  this  incision  the  intussusceptum  is  divided  just  below  the 


9IO 


INVAGINATION. 


neck  and  removed.  A  few  sutures  through  the  edges  of  the  folds 
of  the  intussusceptum  control  the  bleeding.  The  visceral  incision 
is  then  closed  in  the  usual  manner. 

Barker  claims  that  the  operation  requires  much  less  time  than 
the  customary  resection  and  suturing,  but  the  operation  is  liable  to 
be  followed  by  further  invagination.      In  two  cases  operated   upon 


Fig.  525. — Senn's  method  of  resection  of  the  intussusceptum,  and  establishing  an  anas- 
tomosis between  the  intestine  above  and  below  the  neck  of  the  intussuscipiens. 


Fig.  526. — Rydygier's  method  of  resection  of  the  intussusceptum. 

by  Barker,  the  patients'  general  condition  was  so  bad  that  they  died 
of  shock  shortly  after.  In  performing  the  same  operation,  Rydygier 
proceeds  as  follows  : 

Attach  invaginated  portion  to  the  neck  of  the  intussuscipiens  by 
a  running  suture  (Fig.  526).  Incise  sheath  on  convex  side,  below  the 
neck,  longitudinally  ;  amputate  invaginated  portion  ;  suture  cut  end. 


AMPUTATION   OF  INTUSSUSCEPTUM   THROUGH   THE  RECTUM.       911 

especially  of  the  mesenteric  portion,  for  the  arrest  of  hemorrhage  • 
extract  the  resected  portion  through  incision,  or,  if  long  and  access- 
ible, by  the  rectum  from  below  ;  suture  the  incision  •  close  the 
abdomen.  ' 

Maunsell  removes  the  invaginated  portion  in  the  following  man- 
ner :  "  Gently  withdraw  the  intussusceptum  until  its  neck  appears 
outside  the  sht  in  the  intussuscipiens.  Transfix  the  base  with  two 
fine,  straight  needles  armed  with  strong  horsehair,  chromicized  cat- 
gut, or  fine  silkworm-gut.  Now  amputate  the  intussusceptum  a 
quarter  of  an  inch  clear  of  the  needles,  so  as  to  leave  a  fair  stump 
beyond  them.  Transfixing  the  neck  of  the  intussusceptum  previous 
to  Its  amputation  prevents  it  from  flying  back  inside,  and  insures  the 
proper  relati\^e  position  of  the  different  layers  of  the  bowel  previous 
to  sewing  them  up.  Having  amputated  the  intussusceptum  pass 
the  needles  through,  and  pick  up  the  suture  in  the  middle  of  the 
mvaginated  bowel,  divide  it,  and  suture  the  bowel  on  both  sides  ; 
leave  the  ends  of  the  four  sutures  long,  so  as  to  hold  the  cut  ends 
of  the  bowel  in  position  until  it  is  completely  sutured  up  circumferen- 
tially.  Now  cut  off  the  long  ends  of  the  sutures,  apply  Wolfler's 
mixture,  blow  over  with  iodoform,  and  withdraw  the  bowel.  It  only 
now  remains  to  sew  up  the  longitudinal  slit  with  a  continuous  suture." 
Which  one  of  the  operations  that  have  been  devised  for  resection 
of  the  intussusceptum  will  prove  most  successful  will  have  to  be 
determined  by  future  experience.  The  one  proposed  by  me  can  be 
made  in  the  shortest  space  of  time,  and  at  once  secures  a  free  pas- 
sage for  the  intestinal  contents  through  the  anastomotic  opening. 

Amputation  of  Intussusceptum  through  the  Rectum.— In 
cases  of  colic  invagination  with  prolapse  of  the  bowel  from  the 
anus,  Mikulicz  has  described  a  new  operation  for  the  removal  of  the 
invaginated  portion.  The  prolapsed  bowel  is  transfixed  with  two 
ligatures,  which  are  used  for  steadying  the  bowel  during  the  opera- 
tion. The  intussuscipiens  is  then  cut  transversely,  about  one  or 
two  centimeters  from  the  anal  fold.  Step  by  step  the  tissues  are 
divided,  the  hemorrhage  being  arrested  as  it  occurs.  After  division 
of  the  .serous  coat,  any  intestinal  loops  that  may  be  found  in  the 
peritoneal  pocket  are  replaced,  whereupon  the  serous  coats  of  the 
outer  and  inner  cylinders  are  united  with  interrupted  sutures.  When 
this  has  been  done,  the  anterior  half  of  the  intu.ssusceptum  is  cut 
across,  after  which  the  walls  of  both  bowels  are  united  with  deep 
sutures  embracing  all  coats.  In  the  same  manner  the  po.sterior  half 
of  the  intestinal  tubes  is  carefully  divided  and  sutured.  The  hemor- 
rhage from  the  mesentery  must  be  arrested  promptly.  The  sutures 
are  first  cut  long,  so  that  they  can  be  used  to  hold  the  parts  in 
position.  If  the  two  ends  of  the  bowel  vary  so  much  in  size  that 
exact  suturing  can  nf)t  be  done,  the  .space  that  ran  not  be  closed  is 
packed  with  a  .strip  of  iodoform  gauze.  The  after-treatment  con- 
.sists  in  .securing  rest  for  the  sutured  bowel.  All  dressings  and  irri- 
gation of  the  rectum  arc  superfluous  and  might  even  prove  harmful. 


912  IMPACTION    BY    FOREIGN    BODIES. 

A  very  simple  operation  for  rectal  invagination  with  prolapse  of 
the  intussusceptum  was  successfully  performed  in  two  cases  by  von 
Volkmann.  Both  were  children,  aged  one  and  three  years  respec- 
tively. The  operation  was  performed  by  inserting  the  index-finger 
into  the  intussusceptum  as  far  as  the  anus,  when  sutures  were  intro- 
duced with  a  short  curved  needle,  using  the  tip  of  the  index-finger 
as  a  guide  in  such  a  manner  as  to  shut  off  the  peritoneal  cavity 
before  the  prolapsed  portion  was  amputated  on  a  level  with  the  anus 
below  the  line  of  suturing.  In  one  of  the  cases  the  insertion  of  the 
finger  caused  a  rupture  of  the  invaginated  portion  to  the  extent  of 
two  centimeters,  an  accident  to  which  von  Volkmann  called  special 
attention.  After  amputation  of  the  bowel  hemorrhage  was  care- 
fully arrested,  and  the  mucous  membrane  of  the  anus  accurately 
united  with  the  mucous  membrane  of  the  upper  portion  of  the 
bowel  by  suturing.  On  completion  of  the  operation  the  bowel 
retracted,  so  that  the  line  of  suturing  w^as  above  the  anus.  Both 
patients  made  a  rapid  and  permanent  recovery. 

IMPACTION  BY  FOREIGN  BODIES. 

The  term  intestinal  occlusion,  in  the  strict  sense  of  the  word, 
is  applied  most  appropriately  to  that  form  of  obstruction  where  the 
lumen  of  the  bowel  is  occupied  and  completely  or  partially  closed  by 
a  foreign  body  or  an  enterolith.  A  foreign  body  introduced  into  a 
healthy  bowel,  even  if  it  completely  fill  its  lumen,  does  not  necessarily 
produce  intestinal  obstruction,  as  the  healthy  intestine  is  capable  of 
dilatation  to  a  sufficient  extent  to  furnish  an  outlet  to  fluid  intesti- 
nal contents  between  the  wall  of  the  bowel  and  the  foreign  body. 
The  following  experiments  were  made  for  the  purpose  of  studying 
the  effect  of  the  presence  of  a  foreign  body  of  sufficient  size  to  inter- 
fere with  the  passage  of  intestinal  contents,  and  also  with  a  view  to 
ascertaining  if  the  exclusion  of  peristaltic  action  of  a  certain  limited 
segment  of  the  intestine  could  produce  intestinal  obstruction.  The 
operations  were  performed  under  strict  aseptic  precautions,  and  the 
abdominal  incision  was  always  made  through  the  linea  alba.  The 
animals  were  fed  on  the  coarsest  kind  of  food,  and,  as  a  rule,  their 
appetites  were  not  impaired  by  the  operation. 

Experiment  i. — Dog,  weight  thirty-four  pounds.  The  ileum  was  drawn  forward 
into  the  abdominal  wound  and  an  incision  made  about  an  inch  in  length  on  the  convex 
surface,  about  twelve  inches  above  the  ileocecal  valve,  and  through  this  opening  a  stiff 
rubber  tube,  four  inches  in  length  and  three-quarters  of  an  inch  in  diameter,  was  inserted 
in  a  downward  direction.  The  rubber  tube  distended  the  bowel  so  thoroughly  as  to  pro- 
duce a  limited  longitudinal  rupture  of  the  peritoneal  coat.  The  tube  was  pushed  forward 
as  far  as  the  ileocecal  valve,  when  the  intestinal  wound  and  the  peritoneal  rent  were 
sutured.  The  visceral  wound  was  covered  with  an  omental  graft  that  was  sufficiently 
long  to  embrace  the  entire  circumference  of  the  intestine,  and  was  fixed  in  its  place  by 
two  catgut  sutures  that  were  passed  through  the  mesentery  and  both  ends  of  the  graft. 
The  intestine  was  now  thoroughly  cleansed,  dried,  and  returned,  and  the  abdominal 
wound  closed.  The  tube  was  passed  per  rectum  in  .sixty  hours.  No  symptoms  of 
obstruction  were  observed  during  this  time,  and  the  animal  remained  in  perfect  health 
until  killed,  twenty  days  after  the  operation.  The  intestinal  wound  was  recognizable 
upon  the  external  surface  of  the  bowel  by  a  ridge  that  consisted  plainly  of  a  portion  of 


EXPERIMENTS. 


913 


the  omental  flap  ;  the  remaining  portion  had  evidently  disappeared  by  absorption — at  least 
it  had  become  invisible  to  the  naked  eye.  The  interior  surface  of  the  bowel  along  which 
the  rubber  tube  had  to  pass  on  its  way  out  of  the  body  presented  nothing  abnormal. 

Experiment  2. — Dog,  weight  twenty-four  pounds.  In  this  instance  the  incision 
in  the  bowel  was  made  eighteen  inches  above  the  ileocecal  region,  and  instead  of  a  rubber 
tube,  a  glass  tube  three  and  three-quarter  inches  in  length  and  half  an  inch  in  diameter 
■was  introduced  and  pushed  along  the  bowel  until  its  distal  end  was  within  six  inches  of 
the  ileocecal  valve.  Omental  graft  was  made  over  the  visceral  wound.  No  symptoms 
followed.  The  tube  was  passed  in  si.\ty-eight  hours.  The  dog  was  killed  fifty-seven 
days  after  operation.  The  intestinal  canal  was  found  throughout  healthy,  and  the  omental 
graft  had  almost  completely  disappeared. 

Experiment  3. — Dog,  weight  sixty-two  pounds.  Incision  of  bowel  was  made 
twelve  inches  above  ileocecal  region,  and  of  sufficient  size  to  permit  tlie  insertion  of  a 
glass  tube  five-eighths  of  an  inch  in  diameter  and  six  inches  in  length,  which  was  pushed 
in  a  down%Yard  direction  to  within  an  inch  of  the  ileocecal  valve.  The  tube  filled  the 
lumen  of  the  bowel  completely,  but  produced  no  tension  in  the  walls.  No  symptoms 
appeared.  One  month  later  the  abdomen  was  again  opened,  and  the  tube  was  found  in 
the  descending  colon.  The  abdomen  was  closed,  and  the  tube  was  passed  per  rectum 
four  days  later. 

In  these  experiments  hollow  tubes  were  used,  and  it  might  be 
claimed  that  intestinal  obstruction  was  not  produced  because  the 
fluid  intestinal  contents  could  pass  through  the  lumen  of  the  tube. 
The  effect  of  the  peristaltic  action  of  the  bowel  in  that  portion  occu- 
pied by  the  tube  was  certainly  eliminated  as  far  as  the  fecal  circu- 
lation is  concerned,  and  yet  no  symptoms  of  obstruction  during  life, 
were  observed,  and  the  postmortem  appearances  indicated  that  no 
obstruction  had  existed  during  life.  It  is  certainly  surprising  that 
the  peristaltic  action  of  the  intestine  should  be  able  to  force  a  rigid 
tube  of  such  length  and  dimen.sions  as  was  used  in  the  last  two 
experiments  through  the  ileocecal  valve  into  the  colon. 

In  the  following  experiments  the  foreign  body  introduced  was 
of  such  a  structure  that  in  case  it  filled  the  entire  lumen  of  the  bowel 
it  would,  of  necessity,  produce  intestinal  obstruction,  unless  a  space 
for  the  pas.sage  of  intestinal  contents  should  be  created  between  the 
foreign  body  and  the  intestinal  wall  b)'  dilatation  of  the  bowel. 

Experiment  4. — Dog,  weight  thirty-four  pounds.  Intestine  was  incised  at  the 
junction  of  the  ileum  with  the  jejunum,  and  the  closed  end  of  the  barrel  of  a  glass  female 
.syringe,  six  inches  in  length  and  half  an  inch  in  diameter,  was  inserted  in  a  downward 
direction.  The  animal  never  showed  any  untoward  sym])tonis,  and  as  the  syringe  was  nut 
found  in  the  fecal  discharges,  the  animal  was  killed  six  weeks  later,  when  it  was  ascer- 
tained that  it  must  have  ])assed  at  some  previous  time  through  tlie  imrnial  outlet,  as  it 
could  not  be  found  and  the  intestine  i)resented  a  normal  appearance  throughout. 

EXPKKIMKST  5. — Dog,  weight  sixty  pounds.  In  this  exi)eriment  the  incision  in  the 
bowel  was  made  thirty  incJies  above  the  ileocecal  valve,  and  through  it  was  inserted,  with 
considerable  force,  a  glass  female  syringe  six  and  one-half  inches  long  and  three-<|uarters 
of  an  inch  in  diameter,  with  a  metal  cap,  which  considerably  in(nas((l  its  diaincler  at  this 
point.  The  piston  of  the  syringe  projccteii  one  inch  and  a  half  IVoni  liie  caj).  '1  he  per- 
forated end  of  the  syringe  was  directed  <lownward.  Visteral  wound  protected  with  a 
circular  omi^ntal  graft.  For  the  first  few  weeks  the  animal  appeared  to  lie  in  a  good  con- 
dition, and  the  fecal  discharges  were  normal.  Later  the  api)elite  became  im|)aired,  and 
during  the  last  few  days  obstinate  constipation  appeared.  The  dog  was  killed  forty  days 
after  the  inMTtir>n  of  the  foreign  Ixxly.  At  this  time  the  syringe  could  be  plainly  felt 
through  the  alnlominal  wall.  The  syringe  was  found  in  the  ascending  colon,  having 
passed  through  the  ileocecal  valve.  The  ileocecal  region  was  .iisieiided,  and  the  bowel 
at  this  |K)int  was  partially  obslnictcd  by  a  mass  >(  straw,  hair,  fiagmenis  of  bone,  etc., 
for  a  distance  of  about  tin  inches.  Alx.ve  this  |>oint  the  br.wel  was  considerably  dihUeil 
and  contained  liquid  fecal  matter.  .Several  ulcerations  w<-re  found  in  llw  p<)rtion  of  ileutn 
traversed  by  the  .syringe.  'Ihe  lowest  ulcer  was  about  an  in(  h  and  a  half  in  length  and 
58 


914  IMPACTION    BY    FOREIGN    BODIES. 

half  an  inch  in  width,  reaching  as  far  as  the  ileocecal  valve,  and  apparently  of  recent 
date.  The  next  ulcer,  about  one  inch  longer,  but  of  the  same  width,  was  found  six  inches 
higher  up.  This  ulcer  presented  a  gi-anulating  surface  and  beginning  cicatrization.  The 
third  point  of  ulceration,  in  an  advanced  stage  of  cicatrization,  was  twelve  inches  above 
the  ileocecal  valve.  These  ulcers  were  evidently  of  a  traumatic  origin  and  were  undoubt- 
edly caused  by  friction  of  the  intestinal  wall  against  the  projecting  point  of  the  piston  in 
the  attempts  of  the  bowel  to  propel  the  foreign  body  by  increased  peristaltic  action.  In 
this  case  the  intestinal  obstruction  commenced  with  the  accumulation  of  solid  material  on 
the  proximal  side  of  the  syringe,  being  in  reality  not  caused  by  the  foreign  body,  but 
by  the  coprostasis.  Had  this  latter  condition  not  developed,  the  foreign  body  would 
undoubtedly  have  been  expelled  spontaneously  as  in  the  former  experiments. 

These  experiments  fiiriiish  positive  proof  tJiat  a  foreign  body  of 
sufficient  size  to  fill  the  entire  hunen  of  a  healthy  intestine  above  the 
ileocecal  valve  causes  no  obstruction,  ajtd  that  when  obstruction  takes 
place  in  such  instances  it  is  caused  by  tissue  clianges  iji  the  intestinal 
wall  arising  from  prolonged  contact  with  the  foreign  body. 

The  intestines  of  man  can,  of  course,  not  be  compared  with 
those  of  the  dog  in  power  and  capacity  to  propel  foreign  bodies. 
The  intestinal  walls  in  the  dog  are  much  stronger  and  the  canal  is 
much  shorter.  It  is,  however,  somewhat  surprising  that  so  large  a 
foreign  body  as  the  Murphy  button  has  not  more  frequently  be- 
come impacted,  and  that  it  is  so  seldom  a  cause  of  intestinal  obstruc- 
tion. In  the  human  subject  the  passage  of  foreign  bodies  through 
the  intestinal  canal  is  favored  by  a  milk  and  bread  or  potato  diet. 
It  is  claimed  that  such  a  diet  proves  beneficial  by  covering  the  irreg- 
ularities of  the  surface  of  the  foreign  body  with  a  thin,  smooth  in- 
crustation which  diminishes  the  irritation  caused  by  the  passage  of 
the  foreign  body  and  also  the  risk  of  arrest  by  mural  fixation  or 
impaction.  The  Murphy  button  is  smooth  and  hollow  in  the  cen- 
ter, and  consequently  admirably  adapted  for  passage  through  the 
intestinal  canal. 

Enterolithiasis  in  man  is  due,  in  the  great  majority  of  cases,  to 
the  impaction  of  a  gall-stone  or  the  formation  of  an  enterolith  in  the 
lumen  of  the  bowel,  the  nucleus  of  which  is  usually  a  gall-stone. 
It  has  been  a  disputed  question  in  what  way  a  gall-stone  of  sufficient 
size  to  give  rise  to  obstruction  could  enter  the  intestinal  canal. 
Rokitansky  asserted  that  a  calculus  the  size  of  a  hen's  egg  may 
pass  through  the  bile-ducts.  It  is  now  generally  believed  that,  as 
a  rule,  at  least,  such  large  concretions  can  escape  from  the  gall- 
bladder only  by  ulceration  through  its  walls,  or  that  a  gall-stone  of 
smaller  size,  after  it  has  passed  through  the  bile-ducts,  subsequently 
becomes  larger  by  the  formation  of  concentric  concretions  during 
its  retention  in  the  intestinal  canal.  In  reference  to  the  frequency 
of  this  form  of  obstruction,  Leichtenstern  has  found  that  in  1541 
cases  of  intestinal  obstruction  with  different  causes  tabulated  by 
himself,  in  41  it  was  produced  by  gall-stones. 

I  operated  on  a  middle-aged  woman  who  was  suffering  from 
acute  intestinal  obstruction,  and  found,  as  the  cause  of  the  obstruc- 
tion, a  gall-stone  as  large  as  an  English  walnut  firmly  impacted  in 
the  ileum  a  few  inches  above  the  ileocecal  valve.      The  gall-stone 


ENTEROLITH  I ASIS. 


915 


was  removed  by  enterotomy,  and  the  patient  made  a  speedy  re- 
cover)'. 

Campenon  reports  two  cases  of  intestinal  obstruction  caused  by 
impaction  of  a  large  gall-stone  treated  by  laparotomy.  One  re- 
covered, and  the  other  died  of  peritonitis,  caused,  as  he  believed,  by 
separation  of  adhesions  between  gall-bladder  and  intestines  during 
the  operation. 

Korte  operated  four  times  for  obstruction  caused  by  gall-stone ; 
two  of  the  patients  recovered  and  two  died.  In  all  the  cases  the 
foreign  body  was  found  firmly  impacted  and  the  s}'mptoms  were 
very  severe.  Enterotomy  was  made  by  incising  the  bowel  longitu- 
dinally, and  after  extraction  of  the  gall-stone  the  wound  was  sutured. 
Lindner  operated  on  a  similar  case  and,  from  the  clinical  history,  he 
had  reason  to  beheve  that  the  gall-stone  had  been  at  least  six 
months  in  the  intestinal  canal  before  it  gave  rise  to  obstruction. 

Israel  is  of  the  opinion  that  impaction  is  not  always  the  cause 
of  obstruction  in  such  cases,  as  in  one  of  his  operations  he  found 
the  gall-stone  loose  in  the  intestine.  Konig  made  a  postmortem  on 
a  similar  case,  and  believes  that  obstruction  is  sometimes  produced 
by  the  foreign  body  in  its  descent,  by  causing,  as  it  were,  an  invagi- 
nation of  the  mucous  membrane.  In  other  instances  the  foreign 
body  may  produce  irritation  and  enterospasm. 

Wising  collected  51  cases  of  intestinal  obstruction  caused  by  the 
presence  of  a  biliaiy  calculus,  with  the  result  that  only  in  24  of  them 
could  the  anatomic  condition  of  the  gall-bladder  be  ascertained.  In 
18  of  these  the  postmortem  appearances  showed  that  the  calculus 
had  entered  the  intestine  from  the  gall-bladder  by  a  process  of  ulcer- 
ation, and  only  in  3  cases  it  appeared  as  though  the  calculus  had 
passed  through  the  common  bile-duct.  In  33  cases  the  jejunum 
was  12  times  and  the  ileum  21  times  the  place  of  obstruction.  In 
the  21  cases  where  the  calculus  was  impacted  in  the  ileum  the  scat 
of  obstruction  in  2  was  in  the  middle,  in  6  in  the  upper  half,  and 
in  12  in  the  lower  half  of  this  portion  of  the  intestine.  Icterus  was 
observed  only  in  8  of  the  5  i  cases.  The  prognosis  is  always  very 
grave,  as  of  the  51  cases,  38  died.  In  25  fatal  cases  tieath  occurred 
14  times  between  the  sixth  and  the  eighth  day,  while  in  isolated 
cases  it  did  not  occur  until  from  the  ninth  to  the  twenty-eighth  day, 
and  one  patient  died  from  perforative  peritonitis  after  two  months. 
Taking  all  cases  of  obstruction  from  gall-.stones,  it  may  be  statctl 
that  the  seat  of  obstruction  is  located  in  the  lower  portion  of  the 
ileum  in  50  per  cent,  of  the  cases.  The  upper  part  of  the  jejunum 
is  the  next  most  frequent  site  of  obstruction,  and  in  a  few  the  gall- 
stone becomes  impacted  in  the  duodenum,  at  the  site  where  it  has 
ulcerated  through  the  walls  of  the  gall-bladder  and  intestine.  In 
32  ca.ses  collected  by  Leichtenstern,  the  gall-stone  occupieil  the 
duodenum  and  jejunum  in  10  cases,  middle  of  ileum  in  5  ca.ses,  and 
lower  part  of  ileum  in  17  cases.  Treves  is  of  the  opinion  that  gall- 
stones cau.sing  intestinal  obstruction  ulcerate  directly  into  the  intcs- 


.gl6  IMPACTION    BY    FOREIGN    BODIES. 

tine.  He  had  collected  48  cases  of  obstruction  due  to  gall-stones. 
In  the  majority  of  cases  direct  evidence  of  ulceration  between 
the  gall-bladder  and  duodenum  was  to  be  obtained.  The  gall- 
bladder was  entirely  disorganized  in  a  case  in  which  the  gall-stone 
was  supposed  to  have  traversed  the  bihary  ducts.  When  impaction 
takes  place  high  up  in  the  intestinal  tube,  tympanites  may  be 
entirely  absent  and  the  symptoms  point  rather  to  the  existence  of 
pyloric  stenosis  than  to  intestinal  obstruction.  The  higher  the 
location  of  the  impaction,  the  greater  the  probability  that  the  cal- 
culus attained  its  size  within  the  biliary  passages,  and  that  it  entered 
the  intestine  by  a  process  of  ulceration.  In  some  cases  the  commu- 
nication between  the  gall-bladder  and  the  duodenum  remained  at  the 
time  of  death,  showing  that  perforation  had  taken  place  only  recently. 
Wising  has  reported  such  a  case.  The  patient  was  a  woman  sev- 
enty years  of  age,  who  had  never  suffered  from  biliary  colic  or 
jaundice.  The  attack  of  intestinal  obstruction  was  acute,  fecal 
vomiting  being  an  early  symptom  ;  slight  icterus  and  little  tym- 
panites were  present,  and  death  followed  on  the  fifth  day.  At  the 
necropsy  a  biliary  calculus  seven  centimeters  in  length  and  ten  centi- 
meters in  circumference  was  found  firmly  impacted  in  the  ileum. 
The  intestine  on  the  proximal  side  was  found  greatly  distended,  and 
of  a  color  suggesting  incipient  gangrene,  while  the  bowel  below  the 
obstruction  was  pale  and  contracted.  The  gall-bladder  was  ulcer- 
ated and  contracted  by  cicatricial  tissue  communicating  with  the 
duodenum  by  a  perforation  above  the  common  bile-duct.  A  smaller 
communication  was  also  found  between  the  gall-bladder  and  the 
transverse  colon.  Shattock  mentions  a  case  under  the  care  of  Dr. 
Bristowe,  in  which  the  remains  of  the  gall-bladder,  which  was  very 
small,  communicated  directly  with  the  intestine. 

In  some  cases  the  pathologic  conditions  within  and  around  the 
gall-bladder  show  evidences  that  go  to  prove  that  perforation  had 
taken  place  long  before  the  development  of  the  intestinal  obstruction. 
In  such  cases  the  gall-stone  must  have  occupied  the  intestinal  canal 
for  a  variable  period  of  time  without  having  given  rise  to  obstruc- 
tion, the  intestinal  contents  passing  between  it  and  the  intestinal  wall 
in  the  same  manner  as  in  the  experiments  previously  detailed.  In 
some  cases  the  gall-stone  becomes  encysted  and  symptoms  of  ob- 
struction are  not  produced  until  the  size  of  the  stone  has  increased 
by  the  addition  of  concentric  layers  of  concretion.  Harley  reported 
a  case  where  a  gall-stone  became  encysted  in  the  duodenum.  Wood- 
bury reports  a  case  that  came  under  the  observation  of  Dr.  T.  H. 
Andrews,  of  a  woman  sixty  years  of  age,  who  was  suddenly  attacked 
with  symptoms  of  acute  intestinal  obstruction  without  having  pre- 
viously suffered  from  any  disorder  of  the  biliary  passages.  She 
died  on  the  seventh  day.  A  concretion  the  size  of  an  English  wal- 
nut was  found  firmly  impacted  in  the  upper  portion  of  the  jejunum. 
Upon  section  the  concretion  was  seen  to  consist  of  a  brown,  friable, 
cortical   substance,  enveloping  a  dense,  white   crystalline   body  as 


ENTEROLITHIASIS. 

917 

large  as  a  cherry,  which  was  evidenth^  cholcsterin       Tf  . 

m  this  case  a  small  gall-stone  that  had  pa  sed  through  tht^^^^^^^^ 

without  producing  symptoms  was  in  some  ly    eSLd  w'ln 

m  T:T''''  "'"^'  ^^  '  ""^^^^-^  ^orthefc?:-m~f  af  ntfro" 
Jith  01  sufficient  size  to  give  rise  to  intestinal  obstruction 

Badow  reports  the  case  of  a  woman  fifty-seven  vea,-.  nf  . 
who  had  symptoms  of  gall-stone  for  a  year,  ^he  sudcS  ly  deveT 
oped  an  acute  intestinal  obstruction  from  which  she  died  ^  fb.  : 
the  center  of  the  ileum  there  was  found  a  bilty      ,c    us  tlfe  s" 
of  a  walnut,  partially  sacculated.      In  some  rare  cases  tl  e  obstr  r 
tion  IS  caused  by  the  retention  of  numerous  calculi^a  d  Lmsc   bed 
portion  of  the  bowel.      Metcalfe  presented  to  the  New  Y^k  p"  ho 
ogical  Society  a  specimen  taken  from  a  man  fifty-four  ye!. is  of  a^e' 
n  which  the  duodenum  was  occupied  by  numerous  gall-    c^esl' 
such  a  way  as  to  give  rise  to  complete  obstruction.    A^a leu  us  ma 
attain  great  size  before  it  becomes  impacted.    Smith  obse  ved  a  else 
o  acute  intestinal  obstruction  that  proved  fatal  on  the  S  day  and 
nt"'ur  ;:  iTr'r,  '^r'^'  ^^-  --^  ^^  ^e  a  biliary  caL  us 
imoacte^^^^  "'"'''  ^"   circumference,  which  was  found 

he^stontih  '•^^^/fJ^^^^^'/J^^ly  "^^'-«  below  the  p^-loric  orifice  of 
the  stomach.  Clark  relates  the  case  of  a  woman  fifty-eight  years 
of  age  who  died  of  acute  intestinal  obstruction.      Two  la^rge  ^al  ! 

elcrofrhTch"  ""^'T'  r^--^-^-ly  -bove  the  ileocecal  valve, 
each  of  which  was  one  inch  in  length  and  four  inches  in  circumference 
and  together  weighed  one  and  one-quarter  ounces.  The  stone  we,^ 
composed  of  cholcsterin  and  coloring  material  of  bile.  The  intes! 
tine  was  perforated  at  the  seat  of  impaction,  and  a  number  of  small 
gall-stones  were  found  in  the  peritoneal  cavity.  The  biliary  passages 
nonLl  -"d  thickened,  but  the  gall-bladder  appealed   to 'be 

normal  in  size  and  structure  and  not  adherent  to  the  duodenum  • 
jaundice  had  never  exi.sted.      Eight  months  previous  to  the  last  ill^ 
ne.s.s  she  had  a  similar  attack  of  obstruction,  and  at  that  time  a  firm 
swelling  could  be  felt  in  the  right  hypochondriac  region.      This  and 
the  next  ca.se  illustrate  that  the  great  danger  of  impaction  of  a  gall- 
stone consists  of  textural  changes  of  the  intestine  at  the  site  of  im- 
paction.     Meymott's  patient  was  a  woman  forty-seven  years  old 
who  chcd  after  a  short  illmss  during  which  symptoms  of  intestinal 
obstruction  were  well  marked.      At  the  necropsy  a  gall-stone  com- 
po.sed  of  cholcsterin,  and  weighing  400  grains,  was  found  impacted 
ni  the  Ileum,  four  inches  above  the  ileocecal  valve.      At  the  seat  of 
impaction  circumscribed  gangrene  and  perforation  had  taken  place 
i^aggc.  in  his  excellent  paper  "  On  Intestinal  Ob.struction."  gives 
an  account  of  a  case  which  he  examined,  where,  in  a  woman  sixty- 
nine  years  of  age  who  had  died  with  symptoms  of  inteslinal  obstruc- 
tion, a  gall-.stone  measuring  4^  inch.'s  in  ils  largest  circumference 
and  2^  inches  m  its  smallest  was  fcund  impacte.i  in   the  jejunum 
thirty  inches  below  the  pyloric  orifice  of  the  stomach.      The  stone 
had  pa.s.sed  from  the  gall-bladder  into  the  duodenum  tiirough  a  per- 


91 8  IMPACTION    BY    FOREIGN    BODIES. 

foration,  firm  adhesions  having  prevented  its  escape  into  the  perito- 
neal cavity.  In  two  other  cases  to  which  the  same  author  refers 
the  patients  suffered  from  intestinal  obstruction,  and  recovery  fol- 
lowed after  the  evacuation  of  gall-stones  of  immense  size.  In 
cases  terminating  by  spontaneous  recovery  he  believes  that  perfora- 
tion takes  place  into  the  colon.  That  the  danger  is  not  always 
passed  when  a  large  biliary  calculus  enters  the  colon  directly 
through  a  perforation  of  the  gall-bladder  is  well  illustrated  by  a 
case  reported  by  Bourdon,  where  the  calculus  became  lodged  in  the 
sigmoid  flexure,  producing  there  an  inflammation  that  proved  fatal. 
In  a  number  of  cases  recovery  took  place  by  discharge  of  the  cal- 
culus per  vias  natiirales  even  after  the  symptoms  had  pointed  to 
complete  obstruction.  The  largest  stone  which  has  been  success- 
fully passed  was  31^  inches  in  circumference.  Pye-Smith  narrates 
a  case  that  would  tend  to  show  that  in  cases  of  intestinal  obstruc- 
tion due  to  the  presence  of  a  biliary  calculus  a  spontaneous  cure  is 
possible  even  after  the  symptoms  have  continued  for  a  number  of 
days.  The  patient  was  a  female  seventy-eight  years  of  age,  who  had 
never  suffered  from  jaundice  and  gave  no  histoiy  of  biliary  colic. 
She  had  always  been  very  constipated ;  obstruction  finally  ensued, 
and  after  some  temporary  relief  became  complete.  By  external  pal- 
pation no  swelling  could  be  felt.  On  rectal  examination,  however, 
the  finger  could  just  reach  a  smooth,  hard,  movable  tumor,  and  it 
seemed  probable  that  there  was  malignant  disease  of  the  colon. 
After  thirteen  days'  complete  obstruction,  however,  a  large  gall- 
stone was  passed,  and  the  patient  recovered  quickly,  and  has  sub- 
sequently remained  free  from  the  trouble. 

The  clinical  history  of  intestinal  obstruction  by  gall-stones  will 
often  reveal  attacks  of  biliary  colic  and  peritonitis,  which  will  serve 
to  cause  the  physician  to  at  least  suspect  obstruction  from  an  im- 
pacted gall-stone. 

Treatment. — Copious  hot  laxative  enemata  are  always  indicated 
in  the  treatment  of  intestinal  obstruction  by  impaction  of  a  foreign 
body.  Israel  relates  a  case  in  which  this  treatment  was  followed 
by  the  expulsion  of  a  gall-stone  that  had  become  impacted  and  had 
given  rise  to  severe  symptoms  of  obstruction.  Castor  oil  in  cathar- 
tic doses  may  prove  effectual  in  recent  cases.  Enterospasm  caused 
by  the  presence  of  a  foreign  body  may  yield  to  the  administration 
of  opiates. 

Foreign  bodies  when  impacted  in  the  intestine  set  up  inflamma- 
tion, and  this  may  go  on  to  gangrene  and  perforation,  and  so  it  can 
be  explained  how  cathartics  under  such  circumstances  are  more 
likely  to  do  harm  than  good.  If  impaction  has  taken  place  near 
the  ileocecal  valve  or  in  the  colon,  large  injections  and  massage  may 
be  tried,  provided  symptoms  of  severe  inflammation  or  gangrene  at 
the  site  of  impaction  are  absent.  In  the  great  majority  of  cases, 
however,  the  local  lesions  at  the  site  of  impaction  are  of  such  a 
nature  at  the  time  surgical  aid  is  summoned  that  nothing  short  of  a 


TREATMENT. 


919 


laparotomy  will  promise  any  hope  of  success.  It  will  be  well  for 
the  surgeon  not  to  place  too  much  importance  on  the  presence  of 
tympanitic  distention  of  the  abdomen  in  these  cases  as  an  indication 
for  the  necessity  for  an  abdominal  section,  as  this  sign  may  be 
entirely  absent  if  the  impaction  is  located  high  up  in  the  intestinal 
tract ;  if  the  impaction  is  in  the  lower  part  of  the  ileum  or  colon,  an 
operation  should  not  be  postponed  until  such  distention  has  taken 
place.  After  the  abdomen  has  been  opened  in  the  median  line  and 
the  seat  of  obstruction  determined,  the  course  to  be  pursued  will 
depend  upon  the  pathologic  conditions  at  the  seat  of  impaction.  As 
the  mucous  membrane  in  contact  with  the  foreign  bodx^  is  always 
first  to  suffer  in  consequence  of  the  impaction,  puncture  and  incision 
should  be  avoided  at  this  point.  As  the  cases  must  be  few  where 
such  a  stone,  even  soon  after  impaction  has  taken  place,  can  be 
pushed  along  the  intestinal  canal  and  through  the  ileocecal  valve 
into  the  colon,  submural  crushing  of  the  stone  should  be  practised 
when  attempts  at  distant  displacement  have  failed,  and  when  the 
condition  of  the  intestinal  wall  is  such  that  no  fear  need  be  enter- 
tained that  gangrene  or  perforation  will  take  place.  The  stone 
should  never  be  attacked  at  the  seat  of  impaction,  but  should  be 
pushed  in  an  upward  or  downward  direction,  and  then  removed,  if 
possible,  by  breaking  it  up  by  manual  pressure,  or,  if  this  fail,  the 
method  suggested  by  Tait,  of  passing  in  a  needle  obliquely  through 
the  intestinal  wall  and  attacking  the  calculus  in  this  manner,  may  be 
tried.  A  stout  steel  needle,  such  as  is  used  for  electrolysis,  is  best 
adapted  for  this  purpose.  The  needle  should  always  be  introduced 
obliquely  through  the  intestinal  wall,  an  inch  or  two  below  the  im- 
paction, in  order  to  secure  healthy  tissue  for  the  seat  of  puncture. 
After  the  stone  has  been  crushed  and  the  debris  within  the  bowel 
has  been  pushed  into  a  healthy  segment  of  bowel  below,  the  punc- 
ture in  the  serous  coat  should  be  closed  by  drawing  the  peritoneum 
over  it  with  a  fine  superficial  suture,  for  the  purpose  of  guarding 
against  leakage.  When  efforts  at  submural  crushing  or  fracturing 
of  the  enterolith  have  failed  and  it  is  deemed  necessary  to  excise 
it,  it  is  also  advisable  to  push  the  foreign  body  within  the  bowel  in 
an  upward  or  downward  direction  sufficiently  far  to  bring  it  to  a 
perfectly  healthy  portion  of  the  intestine,  as  the  healing  process  of 
the  visceral  wound  made  for  its  extraction  wouki  proceed  more  .sat- 
isfactorily here  than  where  the  tunics  of  the  intestine  have  been 
damaged  in  consequence  of  the  imjjaction.  If  the  .stone  can  not  be 
di.splaced  and  the  incision  must  be  made  through  an  inflamed  intes- 
tinal wall,  a  graft  of  omentum  should  be  placed  around  the  intestine 
after  suturing  the  visceral  wound,  so  as  to  cover  the  wound,  and  its 
ends  fastened  together  by  two  sutures  passed  through  the  mesen- 
teric attachment.  Such  a  procedure  will  place  the  visceral  wound 
in  the  very  best  condition  for  healing,  and  will  furnish  an  additi(»nal 
safeguard  against  subsecjuent  perforation.  If  the  intestine  at  the 
site  of  impaction   shows   evidences   of  gangrene,  or  if    i)erforation 


920  IMPACTION    BY    FOREIGN    BODIES. 

has  already  taken  place,  no  efforts  should  be  made  to  extract  the 
stone,  as  under  such  circumstances  the  surgeon  is  compelled  to 
resect  that  portion  of  intestine  in  which  the  stone  is  imprisoned.  As 
patients  presenting  such  conditions  are  always  more  or  less  col- 
lapsed, it  becomes  of  the  greatest  importance  to  finish  the  operation 
as  rapidly  as  possible  ;  consequently  after  the  resection  has  been 
made  in  the  usual  manner  the  continuity  of  the  intestinal  canal 
should  be  restored  by  an  operative  procedure  that  can  be  executed 
without  unnecessary  loss  of  time.  As  the  bowel  above  the  seat  of 
obstruction  is  always  found  greatly  dilated,  circular  enterorrhaphy 
for  this  reason  alone  would  be  a  difficult,  if  not  an  impracticable, 
task  ;  hence  both  ends  of  the  intestine  should  be  invaginated  to  the 
extent  of  an  inch,  and  the  invagination  maintained  by  three  or  four 
superficial  stitches  of  the  continued  suture,  and  the  continuity  of 
the  intestinal  canal  restored  by  making  an  incision  an  inch  in  length 
in  each  closed  end  of  the  bowel,  on  the  convex  surface,  about  two 
inches  from  the  sutured  extremity,  and  lateral  apposition  of  the 
wounds  secured  by  decalcified  perforated  bone-plates.  The  last 
method  should  always  be  preferred  to  circular  enterorrhaphy  in 
uniting  the  bowel  after  resection  under  such  circumstances,  as  the 
extensive  and  secure  coaptation  of  serous  surfaces  greatly  enhances 
the  chances  of  early  union  between  the  coaptated  bowels,  and  at 
the  same  time  establishes  a  communicating  opening  equally  service- 
able as  after  circular  suturing. 

Intestinal  Concretions. — We  have  already  seen  that  a  small 
gall-stone,  when  retained  for  a  sufficient  length  of  time  in  the  intes- 
tinal canal,  may  become  the  nucleus  for  an  intestinal  concretion  that, 
by  the  addition  of  concentric  layers,  gradually  increases  in  size  until 
it  fills  the  lumen  of  the  bowel,  and,  after  impaction,  gives  rise  to 
intestinal  obstruction.  Enteroliths  causing  obstruction  have  been 
described,  in  Avhich  a  variety  of  foreign  bodies  have  been  found  as 
nuclei. 

Cloquet  divides  the  concretions  found  in  the  alimentary  canal 
into  two  classes.  The  first  includes  enteroliths  in  man  and  bezoars 
in  animals,  both  being  the  result  of  calcareous  deposits  secreted  by 
the  parietes  of  the  intestines.  The  second  class  comprises  abnor- 
mal masses,  such  as  solids  (animal  or  vegetable  hairs  that  have 
escaped  the  process  of  digestion,  and  agglomerate  to  form  segagro- 
pilae),  pulverulent  substances,  and  foreign  bodies,  such  as  stones 
of  fruit,  biliary  calculi,  and  hardened  feces.  He  described  an 
enterolith  that  formed  around  a  pin  as  a  nucleus  by  deposits  of 
phosphate  of  lime,  and  that  had  become  arrested  in  the  cecum, 
where  it  caused  the  death  of  the  patient.  In  another  case  he  found 
that  the  nucleus  was  composed  of  an  ivory  pessary  that  had  per- 
forated the  bowel  on  one  side  and  the  bladder'  on  the  other ;  the 
perforation  in  the  bowel  was  covered  by  a  concretion  of  phosphate 
of  lime,  while  the  part  in  the  bladder  was  incrusted  with  uric 
acid. 


INTESTINAL    CONCRETIONS 

921 

Aberle  reported  a  case  where  chronic  intestinal  ^Kcf       .• 
caused  by  the  presence  of  thirt^-tu•o  e    ero    h     elh  of  wpT  ""' 
composed   of  a  concretion  in   concentric   W?;  a'ou 'd  I  "l       '' 
stone  as  a  nucleus.      The  concretions  had  co   ected    n  the      'P" 
and  were  successfully  removed  by  rectal  imVr  on  .  ''°^°" 

A  chemic  examination  of  the  coifc't^^'  ov  d  ha^  t  wf  ^■'"• 
posed  o  phosphate  of  lime  and  a  consid  "able  cuan tiU-  of'T/ 
animal  glue,  and  traces  of  cholesterin.  ^  '    °^  ^^^• 

Schoor  described  an  enterolith  that  for  five  vears  linM   .• 
to  pain,  first  in  the  ileocecal  region  and  later  in   th     1  rf"  "'^ 
-g>on,  and  was  finally  discharged  spo^l^e!^  U  "       ^  al^^ 
inches   in   length  and    2.9  inches  in  width  and  wei<^l^^^d   .Tq  <^,^ 
On  making  a  section  of  it  it  was  found  that  the  ceiUial  portion^  n 
nuc  eus.  w-as  composed  of  a  triangular  piece  of  bon      ^L^^d  w  ich 
in    concentric    layers,    the   concretion   was    arrancxed        ""^  J^'^'.^- 
examination  of  the  concretion  showed  that  it  u's  far^ly  ton  p^'d 
of  phosphate  of  ammonia  and  magnesia,  the  remaininrpa  t^oft 

rs;:;2rr ''-'-'  -'-^  — ^  °^  ^1..  cSt:::.;: 

an  enJeromh  Thath'  ^""'"^  .'''""  ""'  microscopic  examination  of 
hnfTw  ^     n  ''^'''^'^  symptoms  of  obstruction  in  a  woman 

tr '?  r  r    ^  ^°"^  measured  5  cm.  in  length  and  8.5  cm  in  its 

greatest  circumference.      On  making  a  section^hrough  its  cTnter 
was  seen  to  be  composed  of  a  plum-stone  surrounded  bv  a  si  e 
2   cm.   m     hickness,   made   up   of  concentric   Lners  of  ciTstal   ne 
tliaf  th  '   1    ^'''"''  ^'^  ^  '''^^^'"'^^^  "^^•^^-      C^---  anat    's   owed 

In  Friedlander's  ca.sc  the  obstruction  was  due  to  the  impaction 
of  an  enterohth  m  the  ileum.  30  cm.  above  the  ileocecal  va  ve       I 

s  said  tha  the  apprentices  of  this  trade  not  infrequently  consume 
he  a  cohohc  solution  of  shellac  used  for  varnishing  ;  in  the  stom  ch 
he  alcohol  IS  absorbed  and  the  shellac  is  deposited.      In   thHise 

cretionT'       '""'""'^^  '  '"■^^'  ""'"^'''  "'"  '^''  ^^"^^  ^^'"^  «<"  ^'«"- 

n  April    ,880,  Langenbuch  showed  some  large  concretions,  .some 
01   winch   he  had  removed  by  enterotr.my  \u  a  patient  who  had  suf- 

crcd  from  repeated  attacks  of  intestinal  obstruction.  As  the  symp- 
toms became  more  urgent  and  failed  to  yield  to  simpler  mea.sures 
abdommal  .section  was  performed  in  the  median  line,  and  the  opera- 
tor, without  much  difficulty,  found  a  swelling  in  the  jejunum  laid 
open  the  intestine,  and  removed  the  ma.ss  of  concretions,  wli-ch 
completely  filled  the  lumen  of  the  bouel.  Vomiting  continued 
and  the  patient  died  a  few  hours  after  the  operation.  The  necropsy 
revealed  a  second  ma.ss  in  the  pyloric  region  of  the  stomach  larger 


922  IMPACTION    BY    FOREIGN    BODIES. 

than  the  first.  Virchow  examined  the  concretions  and  found  that 
they  consisted  almost  exclusively  of  organic  substances,  and  espe- 
cially of  the  derivative  of  the  bihary  acids  known  as  dyslysin. 

The  surgical  treatment  of  intestinal  concretions  is  the  same  as 
in  cases  of  impacted  gall-stone. 

Parasites  as  a  Cause  of  Intestinal  Obstruction. — A  few  cases 
of  intestinal  obstruction  have  been  recorded  where  the  obstruction 
was  caused  by  a  mass  of  ascarides  that  interfered  with  the  passage 
of  intestinal  contents  in  the  same  manner  as  an  enterolith.  Halma- 
Grund  refers  to  a  patient  ten  years  of  age  who  came  under  his  care 
suffering  with  the  characteristic  symptoms  of  acute  intestinal  ob- 
struction, followed  by  hemorrhage  from  the  bowels,  collapse,  and 
death.  The  necropsy  revealed,  as  the  cause  of  obstruction,  a  mass 
of  ascarides,  eighteen  in  number,  which  completely  filled  the  lumen 
of  the  ileum.  At  the  site  of  impaction  an  ulcer  was  found,  showing 
an  eroded  vessel  that  had  been  the  source  of  hemorrhage. 

Saurel's  patient,  twenty-three  years  of  age,  suffered  from  symp- 
toms that  resembled  closely  an  attack  of  intestinal  obstruction.  A 
swelling  could  be  felt  to  the  left  of  the  umbilicus.  Two  ascarides 
were  thrown  up  during  a  severe  attack  of  vomiting.  Anthelmintics 
were  administered  and  injections  given  without  any  effect,  and  the 
patient  died  in  collapse.  The  necropsy  revealed  the  cause  of  ob- 
struction to  have  been  a  mass  of  ascarides  that  was  firmly  impacted 
in  the  lower  part  of  the  ileum. 

Pockels  was  called  to  attend  a  patient  who  had  suffered  for 
some  time  from  an  intra-abdominal  swelling  the  size  of  a  hen's  egg, 
which  could  be  distinctly  felt  below  and  to  the  left  of  the  umbilicus. 
A  purge  of  male-fern  and  jalap  expelled  103  ascarides,  after  which 
the  swelling  disappeared  and  the  patient's  health  was  completely 
restored. 

Stepp  has  recorded  an  instance  in  a  boy,  aged  four,  who  died 
with  symptoms  of  acute  intestinal  obstruction  an  hour  and  a  half 
after  medical  aid  was  summoned.  The  postmortem  showed  that 
the  intestine  was  completely  obstructed  by  a  twisted  mass  of  some 
forty  or  fifty  round-worms,  lodged  just  above  the  ileocecal  valve. 
The  ileum  contained  some  thirty-five  more  higher  up,  and  there  were  a 
few  in  the  stomach  and  esophagus.  The  mother  of  the  child  had 
given  the  patient  some  worm  medicine  a  few  days  before  the  acute 
attack,  and  Stepp  thinks  that  the  worms,  weakened  by  the  medicine, 
were  dislodged  in  numbers  by  the  violent  peristalsis  set  up  by  an 
injudicious  diet  afterward,  and  so  rolled  down  in  a  tangled  mass  too 
large  to  pass  the  ileocecal  valve. 

Paul  Simon,  of  Nancy,  reports  the  case  of  a  child,  eleven  years 
of  age,  who  had  been  suffering  with  symptoms  of  intestinal  obstruc- 
tion for  seven  days.  The  most  prominent  symptoms  were  obstinate 
vomiting  and,  on  several  occasions,  hemorrhage  from  the  bowels. 
The  abdomen  was  tympanitic,  very  tender  to  the  touch,  and  a  swell- 
ing could  be  felt  immediately  below  the  umbilicus,  which  was  pain- 


PARASITES    AS    A    CAUSE    OF    INTESTINAL    OBSTRUCTION.  923 

ful  on  pressure.  As  the  ordinary  treatment  afforded  no  relief,  an 
artificial  anus  was  established  in  the  right  iliac  region.  A  large 
quantity  of  fluid  feces  escaped,  followed  by  immediate  collapse  of 
the  distended  abdomen  ;  the  day  following  seven  living  ascarides 
were  discharged  in  a  mass,  and  a  little  later  an  eighth.  The  next 
day  the  bowels  moved  freely  through  the  natural  passage.  San- 
tonin treatment  resulted  in  the  escape  of  three  additional  ascarides. 
The  artificial  anus  was  closed,  and  the  child  made  an  uninterrupted 
recovery.  This  is  the  first  case  of  operative  treatment  of  intestinal 
obstruction  for  this  kind  of  occlusion. 

Two  other  cases  have  been  recorded  in  which  intestinal  obstruc- 
tion of  parasitic  origin  was  relieved  by  operative  treatment.  Roche- 
blanc's  case  was  a  girl  nine  years  old.  The  symptoms  had  existed 
for  four  days  previous  to  the  operation.  Injections  and  cathartics 
proved  of  no  avail.  The  child  complained  of  violent  pain,  which 
became  more  and  more  aggravated  in  the  region  of  the  transverse 
colon.  Opium  had  no  effect  on  the  vomiting  and  pain.  The  abdo- 
men was  distended  and  excessively  tender,  but  an  area  of  dullness 
could  be  made  out  corresponding  to  the  transverse  colon,  and  a  mass 
could  be  distincth'  felt.  In  view  of  the  increasing  intensity  of  the 
symptoms,  operation  was  decided  upon,  and  a  median  incision  made 
from  the  xiphoid  cartilage  to  the  umbilicus.  The  seat  of  obstruc- 
tion was  found  in  the  transv^erse  colon,  at  the  junction  of  the  left 
and  middle  third,  and  consisted  of  a  plug,  conveying  to  the  exam- 
ining finger  the  sensation  of  a  bunch  of  pack  thread.  Gentle 
manipulation  succeeded  in  unrolling  the  mass  and  distinguishing 
three  lumbricoid  worms.  With  careful  massage  they  were  pushed 
along  as  far  as  pos.sible  toward  the  sigmoid  flexure,  when  the  ab- 
dominal incision  was  closed.  Four  hours  after  the  operation  the 
child  felt  completely  relieved  of  pain  and  vomiting  had  ceased.  A 
spontaneous  stool  occurred,  and  an  injection  was  followed  by  sev- 
eral abundant  movements  of  the  bowel  and  the  reestablishment  of 
appetite.  On  the  third  day  calomel  and  santonin  caused  the  expul- 
sion of  the  three  lumbricoids,  after  which  the  child  recovered  rapidly. 

The  presence  of  blood  in  the  stools  in  children  suffering  from 
intestinal  obstruction,  if  invagination  can  be  excluded,  is  a  strong 
indication  of  the  parasitic  nature  of  the  obstruction.  The  obstruc- 
tion itself  is  undoubtedly  caused  more  by  the  irritation  provoked  by 
the  parasites,  abnormal  peristalsis,  and  textural  changes  in  tiie  intes- 
tinal walls  than  occlusion  from  impaction.  Knterotomy  will  .seldom 
become  ncces.sary,  as  the  ma.ss  of  parasites  can  usually  be  unraveled 
and  pushed  downward  into  the  healthy  portion  of  the  bowel  with- 
out a  visceral  incision. 

When  the  surgeon  is  called  upon  to  treat  a  case  of  intestinal 
obstruction  in  a  child,  such  a  cause  should  be  borne  in  nnnd.  as  in 
a  ca.sc  of  this  kind  a  timely  anthelmintic  remedy,  followed  by  a 
bri.sk  cathartic  and  a  high  enema,  may  prove  efficient  in  removing 
the  cause  of  obstruction.      If  such  treatment  slunild  prove  unavail- 


Q24  IMPACTION    BY    FOREIGN    BODIES. 

ing,  no  time  should  be  lost  in  resorting  to  operative  treatment  by 
abdominal  section. 

Fecal  Obstruction. — Fecal  obstruction  is  almost  without  ex- 
ception met  with  only  in  the  large  intestine,  and  here  in  preference 
in  the  cecal  region  or  in  the  sigmoid  flexure.  Cases  have  been 
reported  where  a  congenital  abnormal  dilatation  of  some  part  of  the 
colon  predisposed  to  this  affection.  The  acquired  form  of  dilata- 
tion that  attends  all  cases  is  the  result  of  prolonged  overdistention 
resulting  in  paresis  of  the  distended  segment  of  the  bowel.  It 
occurs  more  frequently  in  women  than  in  men,  and  in  persons 
advanced  in  years  and  leading  a  sedentary  life. 

Boys  de  Loury  has  collected  a  number  of  cases  of  retention  of 
feces  in  the  cecum  and  colon  that  finally  gave  rise  to  inflammation 
at  the  seat  of  impaction  and  intestinal  obstruction.  Among  them 
was  one  observed  by  Nelaton,  where  the  fecal  swelling  occupying 
the  cecurn  and  ascending  colon,  by  pressure  against  the  under  sur- 
face of  the  Hver  and  gall-bladder,  caused  icterus.  The  icterus  and 
symptoms  of  obstruction  disappeared  promptly  after  the  removal  of 
the  fecal  accumulation  by  cathartics.  Retention  of  feces  after  a 
time  produces  more  or  less  acute  enteritis,  attended  by  tympanites, 
pain,  and  dyspnea.  The  patients  usually  have  been  constipated  for 
a  long  time,  constipation  sometimes  alternating  with  diarrhea.  The 
retained  feces  become  inspissated,  hard,  and  form  mural  concretions, 
the  middle  often  remaining  tunneled  for  the  passage  of  fluid  feces. 
The  masses  are  molded,  and,  when  thrown  off,  often  describe  in 
accurate  outline  the  contour  of  the  bowel.  Distention  of  the  bowel 
often  takes  place  to  an  enormous  extent.  Cruveilhier  found,  on 
making  a  necropsy  on  an  old  man,  the  transverse  colon  dilated  so 
that  it  measured  35  cm.  in  circumference.  The  cecum  was  even 
more  dilated  and  was  the  size  of  a  child's  head.  In  one  of  my 
cases  of  periodic  accumulation  of  feces  in  the  sigmoid  flexure  the 
patient  would  return  for  treatment  only  at  a  time  when  symptoms 
of  obstruction  set  in,  and  every  time  he  presented  himself  the  swell- 
ing would  occupy  almost  the  entire  space  in  the  abdomen  below  the 
umbilicus.  Mechanical  removal  of  the  fecal  accumulation,  followed 
by  massage  and  the  use  of  the  faradic  current  and  galvanisqi,  had 
no  effect  in  diminishing  the  size  of  the  bowel  or  in  preventing  the 
periodic  accumulation  of  feces.  If  the  cecum  alone  is  the  seat  of 
impaction,  it  often  presents  the  appearance  of  a  circumscribed  swell- 
ing that  may  be  and  has  been  mistaken  for  an  ovarian  tumor,  abscess, 
or  carcinoma.  The  retained  mass  constitutes  an  irritant  that  sooner 
or  later  causes  a  catarrhal  and  ulcerative  enteritis,  which  extends  to 
the  remaining  tunics  and  is  occasionally  the  direct  cause  of  per- 
foration and  local  or  diffuse  peritonitis.  In  some  instances  the 
inflammation  extends  to  the  connective  tissue  around  the  intestine, 
and  an  abscess  forms  without  an  antecedent  perforation.  The  dis- 
tended bowel  gradually  becomes  paretic,  and  the  local  and  general 
symptoms  are  aggravated.      One  of  the  most  important  diagnostic 


CONGENITAL    NONMALIGNANT    STENOSIS.  925 

points  consists  in  making  pressure  over  the  swelling  in  chloroform 
narcosis,  when  the  fecal  mass  is  indented,  leaving  a  permanent 
depression  at  the  point  of  pressure.  Diarrhea  alternated  by  con- 
stipation is  a  very  frequent  symptom.  If  the  impaction  is  within 
reach,  the  removal  should  be  accomplished  by  the  use  of  a  scoop, 
assisted  by  copious  injections.  If  the  bowel  at  the  seat  of  impac- 
tion has  lost  its  contractility,  cathartics  are  entirely  useless,  and  if 
it  is  in  a  state  of  inflammation,  positively  harmful.  In  such  cases 
gentle  massage,  electricity,  and  high  injections  are  indicated. 

Perforation  and  suppurative  inflammation  in  the  connective  tissue 
surrounding  the  bowel  must  be  met  by  prompt  surgical  treatment. 
In  cases  where  all  ordinary  measures  fail  in  removing  the  fecal 
accumulation,  and  the  symptoms  of  obstruction  continue  unabated, 
it  would  be  not  only  justifiable,  but  good  surgery,  to  cut  down 
upon  the  distended  bowel,  break  up  the  mass  within,  and  push  it 
along  to  a  portion  of  the  intestine  below,  where  peristaltic  action 
has  not  been  impaired.  In  rare  cases,  where  the  intestinal  wall 
presents  pathologic  conditions  that  would  contraindicate  such  a 
course  of  treatment,  it  may  become  necessary  to  resort  to  colotomy 
and  the  removal  of  the  fecal  mass  through  the  wound.  According 
to  circumstances,  either  close  the  visceral  wound  by  suturing,  or 
establish  a  temporary  artificial  anus  by  suturing  the  visceral  into  an 
abdominal  incision  in  the  corresponding  iliac  region. 

Nonmalignant  Stenosis. — Congenital. — Congenital  narrowing 
of  the  bowel  varies  in  degree  from  a  slight  contraction  to  complete 
atresia.  The  experiments  on  artificial  stenosis  of  the  intestines 
referred  to  previously  have  shown  that,  when  the  lumen  of  the 
small  intestine  is  diminished  one-half  in  size  by  partial  enterectomy 
and  suturing  of  the  wound  in  a  direction  parallel  to  the  long  axis 
of  the  bowel,  the  function  of  the  bowel  is  not  impaired  and  obstruc- 
tion does  not  occur,  but  if  the  stenosis  is  carried  beyond  this  point, 
there  is  great  danger  of  obstruction  arising  from  accumulation  of 
solid  intestinal  contents  on  the  pro.ximal  side  of  the  stenosis.  The 
.same  holds  true  of  congenital  stenosis  of  the  small  intestine.  Kven 
if  the  narrowing  is  considerable,  no  serious  symptoms  are  produced 
until  some  foreign  bodies  collect  above  the  seat  of  constriction  and 
cau.se  obstruction  from  occlusion. 

Not  all  ca.ses  of  intestinal  obstruction  developing  soon  after  birth 
are  to  be  attributed  to  congenital  atresia  of  the  intestine.  Chiari 
made  a  po.stmortem  examination  in  a  child  that  died  seven  days 
after  birth  with  .symptoms  of  obstruction.  Atresia  of  the  intestine 
was  found  fifteen  centimeters  above  the  ileocecal  valve  ;  a  defect  of 
the  intestine  five  centimeters  in  length  had  been  caused  by  an  intra- 
uterine invagination  ;  and  the  gangrencnis  intussusceptuin  was  found 
lower  down  in  the  bowel. 

Ixgg  reports  an  exceedingly  interesting  case  where  a  congenital 
steno.sis  of  the  ileocecal  opening  led  to  chronic  obstruction,  dilata- 
tion of  the  ileum,  and  finally  to  perforation  into  the  ascending  c<ilon. 


926  IMPACTION    BY    FOREIGN    BODIES. 

A  female  twenty-six  years  of  age  was  admitted  into  the  hospital  in 
April,  1858.  She  stated  that  since  she  was  five  years  of  age  she 
suffered  from  occasional  attacks  of  colic — perhaps  five  times  during 
a  year — attended  by  constipation  and  vomiting.  After  such  an 
attack  eight  years  ago  a  number  of  cherry-stones  passed  with  the 
feces.  Recently  the  attacks  became  more  frequent,  and  the  last 
was  so  severe  that  she  found  it  necessary  to  seek  admission  to 
the  hospital.  When  admitted,  she  presented  many  symptoms  of 
obstruction.  In  the  right  iliac  fossa  on  percussion  a  dry  crackling 
sound  could  be  heard  and  felt.  In  a  few  days  she  again  passed  a 
few  cherry-  and  plum-stones  and  felt  relieved.  She  was  given  five 
gutta-percha  pills,  which  never  passed  through.  She  left  the  hos- 
pital improved,  and  was  not  seen  again  until  six  years  later.  At 
this  time  she  again  suffered  from  well-marked  symptoms  of  intes- 
tinal obstruction,  and  during  the  first  few  days  vomited  a  number 
of  cherry-  and  plum-stones  and  a  black  round  mass  that,  on  cut- 
ting, was  believed  to  be  one  of  the  gutta-percha  pills  that  she  had 
taken  six  years  before.  Below  the  umbilicus  the  same  crackling 
sound  could  be  heard  and  felt  as  before.  The  symptoms  of  obstruc- 
tion gradually  became  worse,  and  a  few  weeks  after  admission  she 
died.  At  the  necropsy  the  entire  colon  was  found  empty  and  con- 
tracted, the  ileum  very  much  dilated — so  much  so  that  the  lower 
portion  measured  seven  inches  in  circumference.  On  opening  it  fluid 
feces  and  a  few  fruit-stones  escaped.  Ileocecal  orifice  contracted  so 
that  it  would  admit  only  a  No.  9  catheter.  Above  the  ileocecal  valve 
a  communicating  bimucous  fistulous  opening  the  size  of  a  quarter 
of  a  dollar  had  formed  between  the  colon  and  ileum,  and  a  little 
above  this  point  another  but  smaller  opening  had  formed  in  the 
same  manner  by  adhesion  and  perforation.  In  the  small  intestine 
a  pint  of  cherry-stones  was  found,  all  of  them  covered  with  a  black 
crust  that,  on  examination,  proved  to  contain  iron.  This  author 
could  find  in  literature  only  six  cases  of  nonmalignant  stenosis  of 
the  ileocecal  opening.  In  Schroeder  van  der  Kolk's  case  the 
opening  was  even  smaller,  and  in  the  lower  portion  of  the  ileum, 
which  was  enormously  dilated,  a  large  mass  of  cherry-stones  and 
fragments  of  bone  were  found. 

Bourdon  observed  another  case  of  congenital  stenosis  of  the  ileo- 
cecal orifice,  as  narrated  by  Dor.  The  patient  was  a  man,  thirty- 
two  years  of  age,  who  had  suffered  for  a  month  from  pain  in  the 
abdomen,  nausea,  and  vomiting.  The  bowels  were  moved  with 
difficulty  by  cathartics.  On  examination  nothing  could  be  found 
except  a  doughy  condition  of  the  middle  portion  of  the  abdomen, 
where  percussion  revealed  also  a  certain  degree  of  dullness.  He 
remained  two  weeks  in  the  hospital  without  any  improvement  being 
noticeable,  when  he  left,  but  returned  two  days  later.  At  this  time 
an  irregular  uneven  swelling  could  be  distinctly  felt  in  the  right 
groin.  The  swelling  rapidly  increased  in  size,  and  the  patient  died 
in  a  few  days  of  peritonitis.      At  the  necropsy  the  small  intestine 


OCCLUSION    OF    DUODENUM    IN    A    NEW-BORN    CHILD.  92/ 

was  found  very  much  distended,  and  the  colon  and  rectum  were 
contracted  and  empty.  Just  above  the  ileocecal  valve  the  ileum  was 
distended  to  the  size  of  a  fetal  head,  and  adherent  to  the  posterior 
abdominal  wall,  mesentery,  and  intestinal  coils.  The  walls  of  this 
pouch  were  thickened  and  of  a  brown  color.  When  opened,  it  was 
found  to  contain  120  plum-stones  and  92  leaden  bullets.  The  ileo- 
cecal valve  was  nearly  closed,  and  was  permeable  only  to  fluids. 
The  patient  had  probably  swallowed  the  bullets  to  overcome  obsti- 
nate constipation.  In  all  these  cases  of  congenital  stenosis  no  symp- 
toms were  caused  by  the  congenital  defect  until  the  foreign  bodies 
that  collected  above  it  finally  produced  death  from  complete  intes- 
tinal obstruction  or  perforative  peritonitis.  The  clinical  history  in 
each  case  points  distinctly  to  aggravation  of  the  obstruction  b\'  the 
occurrence  of  coprostasis  above  the  seat  of  steno.sis. 

Occlusion  of  Duodenum  in  a  New-born  Child. — Porak  and  Bern- 
heim  describe  a  case  where  a  woman  was  delivered  at  the  eighth 
month  of  a  sickly  female  child.  There  was  hydramnion,  and  over 
six  pints  of  fluid  came  away  during  labor.  There  were  two  small 
fibrous  deposits  in  the  placenta.  On  the  first  day  the  child  vomited 
dark  matter,  each  attack  of  vomiting  coming  on  about  three-quarters 
of  an  hour  after  nursing.  On  the  third  day,  as  no  meconium  had 
passed,  imperforate  rectum  was  suspected  ;  but  a  sound  could  be 
passed  for  over  two  inches  beyond  the  anus.  An  enema  was  given, 
and  a  little  meconium  came  away,  but  the  vomiting  continued,  and 
the  infant  died  on  the  fifth  day.  The  stomach  was  found  much 
dilated  ;  the  lower  part  of  the  large  intestine  was  full  of  meconium, 
but  the  remainder  of  the  intestinal  canal  was  nearly  obliterated. 
The  stomach  communicated  by  a  contracted  orifice,  a[)parently  the 
pylorus,  with  a  blind  pouch  that  had  no  connection  of  any  kind  with 
the  remainder  of  the  intestine,  which  terminated  above  in  a  blind 
extremity  close  to  the  pancreas,  which  opened  into  it.  In  a  similar 
case,  reported  by  Crooks  in  1828,  the  pancreatic  duct  ojicned  into 
the  pouch  connected  with  the  stomach.  Luton  described,  in  1855, 
a  third  case  where  that  pouch  communicated  with  the  blintl  end  of 
the  intestine  by  a  ligament.  There  was  a  similar  breach  of  con- 
tinuity between  the  large  and  the  small  intestine.  No  trace  of 
peritonitic  bands  could  be  seen  in  Porak  and  Hernheim's  case. 

Treatment. — The  surgical  treatment  in  adults  the  subject  of 
congenital  stenosis  sufficient  in  degree  to  cause  intestinal  obstruc- 
tion consists  in  removing  the  impacted  substances  through  an 
incision  above  the  stenosis,  and,  after  clearing  the  bowel  of  its  con- 
tents, uniting  it  with  a  .similar  inci.sion  in  the  bowel  below  the 
obstruction  by  lateral  apposition  with  decalcified  perforated  hone- 
plates,  thus  establishing  a  free  communication  between  the  b(nvel 
above  and  below  the  obstruction,  and,  at  the  same  time,  per- 
manently excluding  from  the  intestinal  circulation  the  functionally 
useless  and  contracted  portion  of  the  intestine.  ICxci.sion  and 
restoration    of   the   continuity  of   the   intestinal   canal    by   circular 


928  STENOSIS. 

enterorrhaphy  can  be  thought  of  only  in  case  perforation  has  takpn 
place. 

If  the  stricture  is  single  and  narrow,^ the  lumen  of  the  bowel 
is  restored  by  enteroplasty,  after  the  method  of  Heineke-Mikulicz 
for  pyloroplasty. 

In  infants  born  with  a  complete  intestinal  atresia  or  a  stenosis 
incompatible  with  bowel  function,  surgical  interference  must  be 
instituted  at  once.  If  the  general  condition  of  the  little  patient  is 
such  as  not  to  admit  of  abdominal  section,  enterostomy  is  indicated 
as  a  life-saving  operation.  Under  such  circumstances  this  operation 
is  very  uncertain  in  its  result,  as  the  obstruction  is  often  located 
high  up  in  the  intestinal  canal,  and,  should  the  patient  recover, 
death  from  marasmus  would  be  certain  in  a  short  time  unless  a 
secondary  operation  is  performed  in  time  to  restore  the  continuity 
of  the  intestinal  canal. 

In  1887  Tischendorf  saved  an  infant  by  this  procedure.  Enter- 
ostomy was  performed  on  the  sixth  day  after  birth  for  what  appeared 
to  be  an  intestinal  obstruction  involving  the  upper  portion  of  the 
intestinal  canal.  The  symptoms  of  obstruction  disappeared  at  once, 
but  the  child  died  three  weeks  later  from  intestinal  disturbance  and 
soor.  The  obstruction  at  the  postmortem  was  found  twenty-five 
centimeters  above  the  ileocecal  valve,  and  consisted  in  a  complete 
atresia  of  the  ileum,  which  was  converted  into  a  string  not  larger 
than  ordinary  twine.  The  part  of  the  intestine  between  the  fistula 
and  obstruction,  a  distance  of  twenty  centimeters,  was  dilated  and 
filled  with  meconium. 

J.  Bland  Sutton  was  able,  from  the  s}'mptoms  presented,  to 
diagnosticate  an  imperforate  ileum  in  a  child  shortly  after  birth,  and 
relieved  the  symptoms  of  obstruction  by  making  an  artificial  anus. 
The  child  was  first  seen  forty-eiglit  hours  after  birth,  when  the 
abdomen  was  found  distended  and  the  child  vomiting  ;  it  had  passed 
nothing  by  the  anus  but  mucus.  The  anus  was  normal,  and  a 
catheter  could  readily  be  passed  into  the  bowel  for  many  inches. 
As  the  child  retained  milk  for  a  time,  imperforate  duodenum  was 
excluded.  The  abdomen  was  explored  with  the  expectation  of 
finding  an  imperforate  ileum.  The  congenital  defect  was  found  at 
a  point  about  eighteen  inches  above  the  ileocecal  valve.  The  distal 
end  of  the  ileum  was  somewhat  shrunken  and  separated  from  the 
proximal  end  by  a  gap  an  inch  across.  The  upper  culdesac  was 
dilated  with  meconium  and  congested  ;  this  was  removed,  and  the 
end  of  the  intestine  stitched  to  the  abdominal  wound.  Meconium 
and  gas  escaped  freely,  the  child  rallied  and  took  food,  and  the  case 
promised  to  go  well  ;  but  about  six  hours  later  the  child  suddenly 
expired.  This  was  a  favorable  case  for  restoring  the  continuity  of 
the  intestinal  canal  by  lateral  anastomosis,  as  the  lumina  of  the  two 
ends  of  the  bowel  were  very  unequal  in  size,  thus  rendering  circular 
enterorrhaphy  after  resection  difficult,  if  not  impossible  ;  moreover, 
lateral  anastomosis  would  have  taken  less  time  than  the  formation 


ACQUIRED    OR    CICATRICIAL.  g2g 

of  an  artificial  anus.  Sutton  is  of  the  opinion  that  congenital  steno- 
sis or  atresia  of  the  duodenum  usually,  if  not  always,  will  be  found 
just  above  the  opening  of  the  bile-duct,  and  in  the  ileum  in  that  part 
where  the  primitive  alimentary  canal  is  in  communication  with  the 
yolk-sac  by  means  of  the  vitelline  duct,  as  in  the  case  he  reported. 

In  infants  enterectomy  for  any  congenital  obstructive  defect  of 
the  intestinal  canal  is  contraindicated,  and  treatment  by  abdominal 
section  and  intestinal  anastomosis  should  always  take  the  place  of 
resection  and  circular  enterorrhaphy,  as  the  operation  can  be  done 
in  a  shorter  time  and  is  attended  by  less  immediate  risk  to  life. 
Felix  Franke  operated  by  this  method  on  a  child  two  days  old. 
Intestinal  obstruction  was  complete.  A  left  lateral  incision  was 
made,  as  it  was  believed  that  the  obstruction  was  located  in  the 
descending  colon  or  sigmoid  flexure.  Dilated  vascular  coils  of  the 
small  intestine  appeared  in  the  wound,  which  terminated  in  a  blind 
end  where  the  intestine  w^as  lost  in  a  small  but  permeable  cord.  An 
anastomosis  was  established  between  the  blind  end  and  the  con- 
tracted part  of  the  bowel,  about  lo  cm.  from  the  seat  of  obstruc- 
tion. The  symptoms  improved  after  the  operation,  but  on  the  third 
day  collapse  suddenly  set  in  and  the  child  died  in  a  few  hours. 
Postmortem  revealed  leakage  and  diffuse  peritonitis.  One  of  the 
sutures  had  given  way,  and  the  fatal  complications  were  traceable 
directly  to  this  cause. 

Wanitschek  made  an  intestinal  anastomosis  for  a  congenital 
obstructive  defect  in  a  child  four  days  old.  The  abdomen  was 
opened  the  entire  length  of  the  linea  alba.  The  small  intestine, 
much  dilated,  vascular,  and  hypertrophic,  presented  itself  at  once, 
and  could  be  traced  into  the  left  iliac  fossa,  where  it  terminated  in 
a  blind  pouch.  Cecum  and  appendix  were  normal  in  location,  but 
contracted,  as  well  as  the  colon.  An  anastomosis  was  made 
between  the  culdesac  of  the  small  intestine  and  the  sigmoid  fie.xurc. 
The  child  never  recovered  from  the  immediate  effects  of  the  opera- 
tion, and  died  in  the  evening  of  the  same  day.  The  postmortem 
showed  that  about  four  centimeters  of  the  lower  portion  of  the 
ileum  consisted  of  a  cord,  which  was  found  attached  to  the 
cecum. 

Acquired  or  Cicatricial. — Cicatricial  stenosis  of  the  intestines  is 
one  of  the  remote  consequences  of  deep  ulcerative  lesions,  such  as 
are  cau.sed  by  dysentery,  typhlitis  stercoralis,  tuberculo.sis,  and 
ileotyphus.  The  cicatrix  that  forms  during  the  reparative  .stage  of 
the  ulceration  contracts  slowly  and  gives  ri.se  to  .stenosis  and  chronic 
intestinal  ob.struction.  As  in  cases  of  congenital  stenosis,  the 
obstruction  often  becomes  complete  and  gives  rise  to  acute  symp- 
toms when  foreign  bodies  or  solid  feces  become  impacted  above  the 
seat  of  constriction.  Not  infrequently  the  cau.ses  that  have  led  to 
cicatricial  .stenosis  are  located  at  the  .same  time  or  appear  succes- 
sively in  different  parts  of  the  intestine,  con.sequently  producing  also 
multif)le  strictures. 
59 


930 


TUBERCULOSIS. 


Sharkey  presented  to  the  Pathological  Society  of  London  a 
specimen  of  multiple  strictures  of  the  ileum  taken  from  a  woman 
thirty-three  years  of  age,  who  had  suffered  frequently  from  indi- 
gestion and  vomiting.  The  immediate  cause  of  death  was  facial 
erysipelas.  The  lower  two-thirds  of  the  small  intestine  exhibited 
numerous  ulcers  apparently  healed.  They  were  so  near  together 
and  produced  such  marked  constriction  that  the  appearance  of  a 
succession  of  pouches  was  simulated.  There  were  no  distinct 
evidences  of  tuberculosis  in  the  intestine  or  any  of  the  other 
organs.  In  the  discussion  that  followed  the  demonstration  of  this 
specimen  Treves  spoke  of  other  somewhat  similar  recorded  cases 
in  which  typhoid  fever  and  tuberculosis  seemed  to  be  excluded. 
Treves  has  described  another  cause  of  cicatricial  stenosis.  He  has 
met  with  such  cases  in  patients  who  suffered  from  a  strangulated 
hernia  when  the  prolonged  compression  during  the  strangulation 
had  produced  a  circumscribed  gangrene  of  the  mucous  coat.  In 
all  the  recorded  cases  the  patients  appear  to  have  recovered 
well  from  the  hernial  trouble,  and,  after  a  varying  time,  gradually 
to  have  developed  symptoms  of  cicatricial  stenosis  of  the  small 
intestine. 

The  most  frequent  cause  of  cicatricial  stenosis  of  the  intestines 
is  tuberculosis.  The  healing  of  a  typhoid  ulcer  is  seldom  followed 
by  cicatricial  contraction.  In  the  large  intestine  dysentery  is  often 
the  cause  of  ulceration,  which  later  leads  to  contraction.  Stric- 
tures of  the  rectum,  in  the  great  majority  of  cases,  are  syphilitic 
or  gonorrheal  in  their  origin.  Intestinal  tuberculosis  deserves 
a  thorough  consideration  in  connection  with  acquired  cicatricial 
stenosis. 

FreqiLency  of  Intestinal  Tuberculosis. — Intestinal  tuberculosis  is  a 
very  common  complication  of  pulmonary  and  miliary  tuberculosis. 
It  is  not  often  met  with  as  a  primary  affection.  In  lOOO  tubercular 
subjects  examined  postmortem  in  the  Pathological  Institute  at 
Munich  between  the  years  1886  and  1890,  only  one  case  of  pri- 
mary intestinal  tuberculosis  was  noted,  while  in  566  cases  secondary 
intestinal  tuberculosis  was  seen. 

That  the  disease  occasionally  occurs  as  a  primary  affection  can 
no  longer  be  doubted  ;  the  results  of  an  enormous  clinical  experi- 
ence and  thousands  of  necropsies  furnish  a  substantial  verification 
of  this  fact.  There  can,  however,  be  but  little  doubt  that  in  many 
cases  of  tuberculosis  of  the  intestine  in  which  the  clinical  features 
point  only  to  this  organ  as  the  sole  seat  of  disease,  careful  search 
would  reveal  old,  perhaps  latent,  tubercular  foci  in  some  other  part  of 
the  body.  The  prudent  surgeon  selects  for  his  operative  work  only 
the  cases  in  which  he  has  reason  to  believe,  from  the  clinical  history 
and  the  signs  and  symptoms  presented,  that  the  disease  is  limited 
and  confined  largely,  if  not  entirely,  to  the  intestinal  canal. 

Etiology. — Primary  tuberculosis  of  the  intestinal  canal  is  the 
result  of  infection  from  without  by  the  ingestion  of  food  contami- 


ETIOLOGY.  Q-j 


nated  with  the  essential  cause  of  the  disease,  the  bacillus  of  tuber- 
culosis,  usually  in  the  form   of  tubercular  milk   and   meat      The 
secondary  form  is  caused  by  autoinfection  by  the  entrance  of  tuber- 
cular sputa    mto    the    intestinal    canal.     The    lymph-follicles    and 
Peyer  s  patches  furnish  the  most  favorable  anatomic  conditions  for 
the  localization  and  growth  of  the  tubercle  bacillus.    Klebs  believes 
that  the   introduction  of  infection  into  the  intestinal   canal  by  the 
swallowing  of  sputa  in  phthisical  patients  is  a  frequent  cause  of  intes- 
tinal  tuberculosis.      He   discovered   two    tubercular  ulcers    in  the 
stomach  of  a  patient  who  had  died  of  pulmonary  tuberculosis      The 
supposition  that  intestinal  tuberculosis  is  caused  often  by  the  ino-estion 
of  tubercular  food   or   sputa  is  supported  by  the   experimelits  of 
Malm,  Parrot,  and  Bonle}-,  who  found  that  animals  fed  with  the  ex- 
pectorations of  consumptives  died  of  tuberculosis  ;  while  Chauveau 
Bollinger,  and  others  succeeded  in  producing  intestinal  tuberculosis 
by  feeding  animals  susceptible  to  the  disease  with  fragments  of  tuber- 
cular lungs  or  with   raw  tubercular  meat.     The  experiments   of 
Gerlach,  Zurn,  and  Klebs  demonstrated  the  dangers  attending  the 
use  of  milk  from   tubercular   cows.      In  these  experiments  ir  was 
noted    that    the    disease    commenced   in  the  form  of  an  intestinal 
catarrh,  and  that  the  extension  of  the  tubercular  infection  began 
through  the  mesenteric  glands  before   the  development  of  dif^ise 
miliar}^  tuberculosis.      W.  Zinn   observed  a  man  twenty-nine  years 
of  age  who,  in  the  course  of  nine  weeks,  died  of  acute  miliary  tu- 
berculosis.     The  autopsy  showed  that  the  miliary  tuberculosis  had 
its  origin  in  a  mass  of  caseous  tubercular  mesenteric  glands.      No 
other  old  tubercular  deposit  could  be  found.      In  the  intestine,  at  a 
point  corresponding  to  the  di.seased  glands,  was  found  the  .scar  that 
followed   the    healing  of  a  tubercular  ulcer.      The  ulcer  was  evi- 
dently the  primary  lesion  that  led  to  tubercuftir  lymphadenitis,  and 
finally  death  followed  from  reinfection  of  the  body  from  the  tuber- 
cular glands  long  after  the  intestinal  ulcer  had  healed.      General 
infection  in  this  case  took  place  through  the  thoracic  duct.     Wyss 
found,  in  seventy-one  postmortems  on  children,  three  instances  of 
undoubted  primary  intestinal  tuberculosis.      In  one  case,  a  girl  five 
and  three-quarter  years  of  age,  who  had  died  of  diphtheria,  a  soli- 
tary tubercular  ulcer  was  found  in  the  ileum,  with  extensive  tuber- 
culosis of  the  mesenteric  glands.      No  trace  of  tuberculosis  couki 
be  detected  in  any  other  organ.      Upon   inquiry  it  was  ascertained 
that   the   child   had  been  fed  on  milk  almost  exciu.sivcly  for  some 
time  before  she  contracted  diphtheria.      In  the  other  two  ca.ses  the 
disease  could  be  traced  to  the  same  cause. 

Intestinal  tuberculo.sis  is  found  most  frequently  in  children  and 
young  adults,  although  no  age  is  entirely  exem])t.  In  the  language 
of  Virchow  :  "  The  predi.spositi'Mi  to  tuberculo.sis,  the  hereditary 
vulnerability,  resides  in  the  tissues,  and  the  younger  and  more 
incompletely  developed  these  are,  the  more  readily  will  the  vulner- 
ability manifest   itself  in   the  presence   of  exciting  cau.ses."      This 


932  TUBERCULOSIS. 

may  explain  the  special  frequency  of  intestinal  tuberculosis  in  chil- 
dren and  in  subjects  affected  by  antecedent  inflammatory  affections 
of  the  intestinal  mucous  membrane. 

Baumers  first  called  attention  to  intestinal  tuberculosis  in  chil- 
dren, which  has  been  known  as  tabes  s.,  phthisis  mesaraica,  febris 
mesaraica,  febris  xanthus  infantum,  and  intestinal  scrofula.  Intes- 
tinal tuberculosis  in  children  results  in  early  and  extensive  infection 
of  the  mesenteric  glands,  from  which  reinfection  usually  terminates 
life  by  miliary  tuberculosis.  Secondary  tuberculosis  appears  to  be 
more  frequent  in  adults  than  in  children.  In  children  intestinal  tu- 
berculosis is  met  with  in  from  30  to  40  per  cent.  ;  in  the  adult,  in 
from  60  to  70  per  cent.  The  local  predisposing  lesion,  although  im- 
portant in  determining  localization,  is  not  essential,  as  the  tubercle 
bacilli  can  penetrate  the  intact  mucous  membrane. 

In  six  of  Czerny's  cases  subjected  to  operative  interference  the 
patients  were  between  twenty-five  and  fifty  years  of  age,  the  average 
age  being  thirty-nine.  In  four  of  the  cases  tuberculosis  was  heredi- 
tary, in  two  cases  the  disease  followed  typhoid  fever,  and  in  one  it 
was  preceded  by  an  acute  attack  of  parametritis.  In  three  of  the 
cases  the  intestinal  disease  was  complicated  by  pulmonary  tubercu- 
losis, and  in  one  by  diffuse  miliary  tuberculosis.  In  one  case  the 
infection  occurred  by  the  rupture  of  a  tubercular  adnexal  abscess 
into  the  intestine,  and  in  another  the  intestinal  tuberculosis  was 
complicated  by  actinomycosis. 

Clinical  experience  has  shown  that  intestinal  tuberculosis 
pursues  a  more  benign  and  chronic  course  in  the  adult  than  in 
children,  and  consequently  the  primary  form  of  intestinal  tubercu- 
losis amenable  to  successful  surgical  treatment  is  met  with  most 
frequently  in  young  adults  and  persons  of  advanced  age,  seldom  in 
the  case  of  infants  anl^  young  children. 

Infection  from  the  blood  is  undoubtedly  of  quite  common 
occurrence  in  primary  and  secondary  intestinal  tuberculosis.  The 
most  favorable  cases  for  successful  surgical  intervention  are  those 
in  which  a  locaHzed  predisposing  lesion  furnishes  an  infection  atrium 
for  the  entrance  of  tubercle  bacilli  into  the  tissues.  These  are  the 
cases  in  which  characteristic  solitary  or  multiple  tubercular  ulcers 
develop  that  manifest  an  intrinsic  tendency  to  heal,  and  in  which  an 
operation  finally  becomes  a  necessity  after  symptoms  of  obstruction 
indicate  the  existence  of  a  cicatricial  stenosis. 

Pathology. — Intestinal  tuberculosis  presents  itself  clinically  and 
pathologically  in  the  form  of  a  chronic  catarrhal  or  ulcerative 
enteritis.  The  inflammation  that  follows  the  tubercular  infection  is 
characterized  by  a  series  of  pathologic  processes  common  to  all 
tubercular  affections,  influenced  and  modified,  however,  by  the 
structure  and  function  of  the  tissues  involved.  The  primary  seats 
of  infection  are  the  glandular  appendages  of  the  mucous  membrane, 
the  lymph-follicles,  and  Peyer's  agminated  glands.  The  mode  of 
infection  resembles   typhoid   fever   in   many  respects.      The  lower 


PATHOLOGY. 


933 


portion  of  the  ileum  and  the  ileocecal  region  are  the  most  frequently 
infected,  although  any  portion  of  the  intestinal  canal  may  be 
involved  primarily  or  by  extension.  Of  six  cases  of  intestinal 
tuberculosis  reported  by  Schiller  that  were  operated  upon  by 
Czerny  during  a  period  of  four  years,  the  disease  involved  the 
ileocecal  region  four  times  and  the  descending  colon  twice.  In  all 
cases  of  cecal  tuberculosis  operated  upon  by  Czerny,  the  ulceration 
was  limited  on  one  side  by  the  ileocecal  valve ;  the  mucous 
membrane  of  the  cecum  was  extensively  ulcerated,  presenting 
elevations,  depressions,  and  polypoid  excrescences  between  the 
ulcers ;  the  cecal  wall  was  much  thickened  and  indurated.     The 


Fig.  527. — Diffuse  annular  tubercular  ulcer  of  ileum  (Pathological  Museum,  Rush 

Medical  College). 


Fig.  528. — Tubercular  ulcer  of  ileum  (Pathological  Museum,  Rush  Medical  College) 
a.   Round  tubercular  ulcer  ;  I),  narrow  circular  tubercular  ulcer. 


lumen  of  the  cecum  was  usually  foimd  contracted,  the  .stenosis 
being  the  direct  cause  of  the  intestinal  obstruction.  In  one  case 
the  mechanical  impediment  was  found  to  be  a  sharp  flexion  at  the 
in.sertion  of  the  ileum  into  the  cecum.  In  one  case  the  contracted 
lumen  of  the  cecum  was  divided  by  a  band  of  cicatricial  ti.ssiie. 
The  bowel  below  the  obstruction  was,  as  is  always  the  case,  nearly 
empty,  reduced  in  size,  and  anemic,  while  <jn  the  j)rf)xim.'il  side 
reverse  conditions  exi.sted,  which  facilitated  circular  suturing  after 
exci.sion.  In  acute  cases,  such  as  are  ob.served  in  children  and  that 
.seldom  come  to  the  notice  of  the  surgeon,  the  di.sease  is  usually 
diffuse  and  often  implicates  a  large  .section  f»f  the  intestinal  canal 
above  the  ileocecal  valve.      Tuberculosis  is  likely  to  attack  a  portion 


934 


TUBERCULOSIS. 


of  the  intestinal  canal  subjected  to  mechanical  irritation,  as  is  the 
case  in  hernia. 

A  number  of  cases  of  tuberculosis  of  hernia  have  been  reported. 
Bruns  adds  one  new  case  to  those  previously  published.  In  these 
13  cases  the  hernial  sac  was  attacked  10  times,  and  in  7  it  alone 
was  the  seat  of  disease.  This,  together  with  other  conclusions, 
substantiates  the  belief  that  "  tuberculosis  of  hernia"  may  occur  as 
a  primary  disease  ;  generally,  however,  it  is  associated  with  perito- 
neal tuberculosis. 

It  appears,  from  the  present  literature  on  the  subject,  that  tuber- 
culosis in  the  ileocecal  region  and  the  colon  is  usually  a  disease  of 
adults,  although  there  are  a  few  cases  on  record  in  which  the  intes- 
tinal canal  at  and  below  the  ileocecal  region  was  affected  in  children 
not  more  than  ten  years  of  age. 

Reclus  has  called  attention  to  the  rapidly  increasing  number  of 
cecal  tuberculosis  cases  that  have  been  operated  upon.  The  cases 
of  Bouilly,  Terrier,  Hartmann,  Reynier,  Broca,  Roux,  Salzer,  Bill- 
roth, and  Hochenegg,  the  anatomic  researches  of  Duguet,  Spill- 
mann,  Herard,  Cornil,  and  Hanot,  and  the  more  recent  descriptions 
of  Pilliet  and  of  Le  Bayou,  have  thrown  some  light  upon  this 
hitherto  but  little  recognized  affection.  This  disease  may  manifest 
itself  as  a  localized  tuberculosis  without  infiltration  and  as  a  purely 
local  disease.  This  suffices  to  place  this  intestinal  lesion  among 
the  surgical  tuberculoses.  From  the  moment  it  is  a  limited  focus 
and  this  focus  is  accessible,  in  such  favorable  circumstances  in- 
tervention is  legitimate.  The  greatest  number  of  cases  of  cecal 
tuberculosis  so  far  reported  have  been  over  twenty-five  years  of 
age. 

It  seems  that  two  distinct  anatomicopathologic  forms  may  be 
described,  associated  with  different  symptoms — the  one  a  fibrous 
and  the  other  an  ulcerating  variety ;  moreover,  these  may  be  com- 
bined, or  there  may  be  noticed  many  intermediate  stages  between 
the  varieties.  The  majority  of  cases  thus  far  reported  have  been 
characterized  by  an  abundant  tissue  proliferation,  which  imparted  to 
the  swelling  much  of  the  aspects  of  carcinoma.  The  inflammatory 
mass  is  almost  always  found  freely  embedded  in  plastic  adhesions, 
and  it  is  difficult,  if  not  impossible,  to  outline  the  anatomic  land- 
marks of  the  parts  involved.  Ordinarily  the  lesions  are  most 
marked  around  the  ileocecal  valve.  The  appendix  is  generally 
affected  and  constitutes  a  portion  of  the  inflammatory  mass. 

The  second  or  ulcerated  form  may  present  thickening  of  the 
peritoneum  and  adhesions  around  the  intestinal  loops,  but  these 
have  not  the  remarkable  hypertrophy  of  the  other  form  ;  on  the 
contrary,  the  ulcerative  process  predominates,  and  the  mucosa  has 
often  completely  disappeared,  especially  at  the  site  of  the  ileocecal 
valve.  Ulceration  often  leads  to  abscess  and  fistula  formation. 
The  fistulous  openings  are  frequently  multiple. 

Cornil  believes  that  in   such  cases  the  primary  infection  takes 


PATHOLOGY. 


935 


place  in  the  appendix  vermiformis,  more  especially  when  it  is  the 
seat  of  a  fecal  concretion  or  foreign  body. 

The  tubercular  infection  may  take  place  in  the  upper  portion  of 
the  intestinal  canal.  Claude  made  a  postmortem  on  a  man  thirty- 
three  years  of  age  who  had  died  of  pulmonary  tuberculosis.  He 
found  tubercular  ulcers  in  the  upper  portion  of  the  duodenum  ; 
four  other  ulcers  were  found  in  the  ileum.  He  attributed  the 
intestinal  disease  to  infection  from  the  blood.  During  life  this  pa- 
tient never  showed  any  symptoms  referable  to  the  intestinal  canal. 
The  tubercular  nature  of  the  intestinal  affection  was  established  by 
histologic  and  bacteriologic  examinations. 

The  entire  length  of  the  intestinal  canal  is  seldom  affected  by 
tuberculosis,  and  in  the  exceptional  instances  when  this  is  the  case, 
the  disease  pursues  a  rapidly  fatal  course.  It  has  already  been 
stated  that  intestinal  tuberculosis  always  begins  in  the  h'mph- 
follicles  or  Peyer's  patches.  The  tubercular  process  is  at  iirst  sub- 
mucous, and  reaches  the  surface  only  after  degeneration  and  ulcera- 
tion have  taken  place.  The  glands  become  swollen,  and  can  be  felt 
under  the  epithelial  lining  as  small  hard  nodules  which  present  a 
grayish  color  before  caseation  sets  in.  With  the  onset  of  caseation 
the  swelling  increases  in  size  and  assumes  a  yellowish  color.  As 
soon  as  the  overlying  epithelial  lining  is  destroyed,  softening  of 
the  inflammatory  product  and  ulceration  set  in.  The  primary 
ulcer  is  small  and  round,  with  yellowish  margins.  At  the  time  the 
crater-like  defect  takes  place  the  mass  is  not  larger  than  a  hemp- 
seed.  Such  small  ulcers  may  heal,  but  more  frequently  progressive 
extension  takes  place  in  the  direction  of  the  blood-vessels.  In 
Peyer's  patches  the  appearance  of  sieve-like  defects  can  be  seen 
during  the  early  stages  of  the  disease,  which  Rokitansky  described 
as  primitive  tubercular  ulcerations.  They  constitute  the  evolution 
stage  of  secondary  tubercular  ulcers.  Kven  in  superficial  ulcers 
tubercles  can  constantly  be  found  between  the  muscular  fibers.  By 
confluence  and  progressive  infection  the  surface  defects  increase 
in  size.  Not  infrccpiciitly  remnants  of  intact  mucous  membrane 
remain  between  the  different  points  of  ulceration.  The  shape  of 
the  ulcer  is  variously  modified  by  the  confluence  of  several  ulcers. 
The  most  extensive  ulcers  are  found  in  the  cecum,  colon,  and  ter- 
minal portion  of  the  ileum. 

The  intrinsic  tendency  of  intestinal  tubercular  ulcers  is  to  in- 
crease in  size  in  the  direction  of  the  blood-vessels, — that  is,  trans- 
versely to  the  long  axis  of  the  bowel  (see  Figs,  527  and  528), — a 
pathologic  feature  that  was  first  pointed  out  by  Rokitansky.  The 
tubercular  infection  follows  the  lymph  sheath  of  the  biood-vcs.sel.s. 
Through  the  lymphatics  the  infection  extends  to  the  .serosa,  upon 
the  surface  of  which  miliary  tubercles  are  often  found  over  an  area 
corresponding  in  extent  to  the  ba.sc  of  the  ulcer.  The  mesenteric 
glands  are  infected  through  the  .same  channels  (Plate  8).  In  chil- 
dren the  mesenteric  glands  are  often  affected  without  an  antecedent 


936  TUBERCULOSIS. 

intestinal  lesion.  In  such  cases  the  tubercle  bacilli  penetrate 
through  the  mucous  membrane  and  enter  the  lymphatic  system 
without  producing  a  demonstrable  surface  lesion,  or  infection  takes 
place  by  the  way  of  the  general  circulation.  Infection  through  the 
mucous  membrane  undoubtedly  is  often  determined  by  catarrhal 
enteritis,  which  damages  the  epithelial  lining  and  prepares  the  way 
for  invasion  from  the  intestinal  canal. 

Extension  of  the  ulcer  in  the  muscular  coat  occurs  by  progres- 
sive extension  of  the  ulcerating  process  and  by  diffusion  of  the  in- 
fection through  the  lymph-channels.  As  soon  as  the  serous  coat 
is  reached,  secondary  plastic  peritonitis  is  the  almost  constant  result. 
Usually  the  peritonitis  is  limited  to  the  affected  portion  of  the  bowel, 
between  which  and  the  adjacent  viscera  firm  adhesions  are  formed. 
In  exceptional  cases  the  peritonitis  becomes  profuse  without  perfora- 
tion. More  frequently,  however,  the  diffuse  tubercular  peritonitis  is 
caused  by  the  rupture  of  a  peri-intestinal  tubercular  abscess.  Per- 
foration of  a  tubercular  ulcer  is  often  prevented  by  early  and  firm 
adhesions.  In  one  of  the  cases  reported  by  Rindfleisch  the  intes- 
tine was  found  perforated  at  five  different  points  without  causing 
diffuse  peritonitis,  owing  to  the  existence  of  firm  adhesions.  Perfora- 
tive peritonitis  is  so  rare  in  intestinal  tuberculosis  that  Leube  saw 
but  2  cases  during  his  service  in  the  clinic  at  Erlangen.  Leudet 
reports  6  cases  that  occurred  in  his  practice,  which  were  due  to  tu- 
bercular affection  of  the  appendix.  Eisenhardt  found  perforation 
in  28  out  of  566  cases  of  intestinal  tuberculosis  examined  postmor- 
tem. Extension  of  the  disease  to  other  parts  and  organs  frequently 
takes  place  through  the  lymphatic  system. 

Tubercular  lymphadenitis  is  a  frequent  and,  in  long-standing 
cases,  a  constant  concomitant  pathologic  condition,  as  was  first 
pointed  out  by  Schiippel  and  Rindfleisch.  The  observations  occur- 
ring during  operations  made  for  intestinal  tuberculosis  and  the  re- 
sults of  po.stmortem  examinations  combine  to  show  that  retrograde 
metamorphosis  of  the  inflammatory  product  of  the  tubercular 
glands  takes  place  very  slowly.  I  have  repeatedly  seen  tubercular 
mesenteric  glands  as  large  as  a  hazelnut  that  had  not  undergone 
any  decided  cheesy  degeneration.  Coagulation  and  caseous  degen- 
eration, however,  occur  in  the  course  of  time,  but  liquefaction  and 
abscess  formation  in  and  around  tubercular  mesenteric  glands  are 
of  rare  occurrence.  Infiltration  and  thickening  of  the  intestinal 
wall  occur  most  frequently  and  reach  the  maximum  height  in  cases 
in  which  the  tuberculosis  is  located  in  the  ileocecal  region  or  colon. 
In  these  localities  the  disease  is  most  commonly  primary,  a  fact  that 
would  explain  its  chronicity  and  comparatively  benign  nature. 
When  the  tubercular  process  affects  this  part  of  the  intestinal  canal, 
the  resultant  swelling  is  often  of  larger  size  and  has  very  often  been 
mistaken  for  malignant  disease.  In  such  instances  the  intestinal 
wall  has  been  found  several  centimeters  in  thickness. 

In  acute  cases  of  intestinal  tuberculosis  the  ulcers  manifest  little 


Plate  8. 


^ 


to  ^ 
a,  J 

S  -^ 


•?  a 


SYMPTOMS.  o-.T 


or  no  tendency  to  repair.     In  chronic  cases  an  attempt  at  healincr  or 
complete  heahng  is  the  rule.      Eisenhardt,  in  examinin-  the  p1)st 
mortem  records  of  566  cases  of  intestinal  tuberculosis ''found  that 
heahng  was  completed  in  only  10,  while  in  25  instances  the  ulcers 
were  only  partl\'  healed. 

Attempts  at  cicatrization  are  frequently  seen,  but  very  often  while 
heahng  is  going  on  in  one  part  of  the  ulcer,  progressive  infection  and 
destruction  are  witnessed  in  another  portion.  The  healing  of  a 
tubercular  ulcer  of  large  size  requires  an  enormous  quantity  of  new 
material,  which  is  composed  largely  of  new  connective  tissue.  The 
scar  tissue  always  evinces  a  tendency  to  contraction,  which  leads  to 
stenosis  and  flexion.  If  the  ulcer  is  circular,  healing  is  attended  by 
contraction  of  the  lumen  of  the  bowel,  which  finally  leads  to  intes- 
tinal obstruction.  If  only  one  side  of  the  circumference  of  the  bowel 
IS  ulcerated,  healing  will  result  in  contraction  and  flexion.  The 
healing  of  several  tubercular  ulcers  gives  rise  to  the  development  of 
multiple  strictures,  which  have  been  found  by  several  surgeons  in 
operations  for  intestinal  obstruction.  Progressive  cicatiictal  con- 
traction may  eventually  result  in  almost  complete  obliteration  of  the 
lumen  of  the  bowel.  In  one  of  Scheuer's  ca.ses  the  stricture  at  the 
time  the  intestinal  resection  was  performed  for  obstruction  was  so 
narrow  that  it  admitted  only  a  probe  three  millimeters  in  size.  The 
healing  of  intestinal  tubercular  ulcers  is  seldom  followed  by  com- 
plete recovery,  as  all  such  patients  are  liable  later  to  intestinal 
obstruction  and  reinfection  from  the  tubercular  mesenteric  and  retro- 
peritoneal glands. 

Symptoms. — Intestinal  tuberculosis  may  run  its  entire  course 
from  beginning  to  end  without  any  symptoms  that  would  point  to 
the  intestinal  canal  as  the  principal  seat  of  the  disease.  Tubercular 
ulcers  of  the  intestines  are  often  found  at  autopsies  without  the 
slightest  evidence  of  their  existence  during  life.  That  an  i.solated 
tubercular  ulcer  of  the  intestine  may  exist  without  cau.sing  symptoms 
before  perforation  occurs  is  shown  by  a  case  reported  by  Kaum- 
garten.  A  young  soldier  in  almost  perfect  health  died  suddenly  of 
perforative  peritonitis.  The  postmortem  revealed,  as  the  cause  of 
the  peritonitis,  a  solitary  perforated  ulcer  the  size  of  a  penny  in  the 
lower  portion  of  the  ileum.  Microscopic  examination  of  the  tissues 
demonstrated  the  tubercular  nature  of  the  ulcer.  No  evidence  of 
tuberculosis  was  found  in  any  other  organ  of  the  body. 

In  other  cases  the  sym[)toms  are  misleading.  Thus,  Leonhardi- 
A.ster  recorded  a  case  of  intestinal  tuberculosis  that  presented  all 
the  clinical  features  of  pernicious  anemia,  the  intestinal  .symptoms 
being  masked  by  the  progressive  anemia,  for  which  no  cause  could 
be  assigned  until  the  necrf)p.sy  revealed  the  characteristic  pathologic 
lesions  of  intestinal  tuberculosis.  In  ca.ses  of  diffu.sc  acute  intestinal 
tuberculo.sis  the  mo.st  important  and  prominent  symptoms  point  to 
the  exi.stence  of  an  intestinal  catarrh.  j'rofuse  diarrlu-.i  is  .seldom 
ab.sent,  the  stools  being  copious  and  licjuid.      Colicky  pains  referred 


938  TUBERCULOSIS. 

to  the  umbilicus,  slight  tenderness  on  deep  pressure,  progressive 
emaciation,  and  more  or  less  rise  in  temperature,  especially  toward 
evening  and  during  the  night,  are  symptoms  well  calculated  to  arouse 
suspicion  in  regard  to  the  probable  tubercular  nature  of  the  intestinal 
disease.  Enlarged  mesenteric  glands  can  often  be  palpated  through 
the  thin  and  relaxed  abdominal  wall.  In  some  cases  enlarged  mes- 
enteric and  retroperitoneal  glands  can  be  detected  by  vaginal  or 
rectal  examination.  The  severity  of  the  diarrhea  is  attributable 
more  to  the  existence  of  the  complicating  intestinal  catarrh  and  in- 
creased peristalsis  than  to  the  ulcers  themselves.  Pulmonary  tuber- 
culosis, as  well  as  tuberculosis  of  any  other  important  organ,  often 
overshadows  and  masks  the  intestinal  complication.  In  all  cases 
of  pulmonary  tuberculosis  attended  by  diarrhea  that  does  not  yield 
to  the  ordinary  treatment,  we  have  reason  to  assume  the  existence 
of  intestinal  tuberculosis.  In  primary  intestinal  tuberculosis  the 
early  symptoms  set  in  insidiously ;  the  disease  is  usually  mistaken 
for  an  ordinary  intestinal  catarrh,  and  is  regarded  as  such  until  the 
negative  results  obtained  from  the  treatment  induce  the  physician 
to  make  a  more  thorough  investigation  of  the  case.  The  suspicion 
of  the  tubercular  nature  of  the  intestinal  disease  is  materially 
strengthened  if  it  can  be  ascertained  that  the  patient  has  made 
unsterilized  milk  a  staple  article  of  diet. 

The  frequent  presence  of  traces  of  blood  in  the  stools  is  decid- 
edly suspicious.  If  the  ulcers  are  located  in  the  small  intestine, 
the  blood  is  intimately  mixed  with  the  stools  ;  if  in  the  large  intes- 
tine, the  extravasated  blood  often  forms  a  coating  for  the  otherwise 
well-formed  fecal  masses.  Pus  in  the  stools  is  found,  as  a  rule, 
only  when  the  tubercular  process  involves  the  lower  portion  of  the 
large  intestine.  In  the  small  intestine  the  pus  that  forms  on  the 
surface  of  the  ulcers  is  speedily  washed  away  with  the  intestinal 
discharges,  and,  on  the  other  hand,  pus-formation  is  checked  by  the 
peptic  action  of  the  intestinal  juice,  which  acts  as  an  efficient  anti- 
septic. Bamberger  has  called  attention  to  the  character  of  the 
stools  in  intestinal  tuberculosis,  which,  according  to  this  authority, 
frequently  contain  transparent  particles  of  mucus  resembling  frog 
spawn  or  boiled  sago  grains.  These  masses  of  mucus  are  probably 
formed  in,  and  are  discharged  from,  the  lymph-follicles  of  the  intes- 
tinal mucous  membrane,  the  structures  primarily  affected  by  the 
tubercular  process. 

Virchow  places  less  diagnostic  importance  on  the  presence  of  this 
pathologic  product,  which  he  believes  has  often  been  mistaken  for 
partially  digested  starch. 

The  partial  or  complete  healing  of  a  tubercular  ulcer  of  consid- 
erable size  is  usually  announced  clinically  by  the  appearance  of  a 
complexus  of  symptoms  that  indicates  the  existence  of  chronic 
intestinal  obstruction,  caused  by  the  cicatricial  stenosis  that  so 
constantly  attends  and  follows  the  healing  of  a  tubercular  ulcer. 
Intermittent  colicky  pains  in  the  umbilical  region,  diarrhea  alternated 


SYMPTOMS. 


939 


with  constipation,  and  perhaps  occasional  attacks  of  vomiting,  are 
the  most  prominent  clinical  manifestations  in  such  cases.  Chronic 
intestinal  obstruction  from  this  cause,  as  well  as  from  other  causes, 
often  terminates  in  an  acute  attack.  In  rare  cases  the  chronic 
obstruction  presents  (ew  or  no  symptoms  until  symptoms  of  acute 
obstruction  set  in,  when  operation  or  autopsy  reveals  the  presence 
of  an  old  cicatricial  stenosis  that  has  not  been  suspected  before  the 
abdomen  is  opened. 

The  formation  of  a  chronic  abscess  in  the  ileocecal  region,  or  in 
any  part  of  the  abdominal  wall,  in  connection  with  intestinal  symp- 
toms of  long  standing,  always  suggests  the  probable  existence  of  a 
tubercular  intestinal  ulcer.  I  have  always  observed  these  in  the 
ileocecal  region,  over  the  ascending  colon,  and  in  one  case  in  the 
umbilical  region.  These  are  the  cases  in  which,  prior  to  the  perfo- 
ration of  the  ulcer,  adhesion  takes  place,  excluding  the  peritoneal 
cavity,  and  is  followed  by  the  formation  of  a  mural  tubercular 
abscess.  In  more  than  one  case  tlfe  tubercular  nature  of  the 
abscess  and  its  intestinal  origin  were  predicted  before  the  abscess 
was  opened.  A  fecal  fistula  is  sure  to  follow  the  opening  of  such 
an  abscess.  The  granulations  lining  the  abscess  cavity  may  for  a 
time  prevent  the  escape  of  intestinal  contents,  hut  in  the  course  of 
a  few  days  or  weeks  the  granulations  give  way  and  the  fecal  fistula 
appears.  If  the  disease  is  attended  by  plastic  peritonitis  to  any 
considerable  extent,  the  inflammatory  e.xudate  may  often  be  dis- 
tinctly outlined  by  palpation. 

Voehts  calls  attention  to  a  condition  of  diagnostic  value,  often 
met  with  in  such  cases,  in  the  form  of  indurated  plates  in  the  peri- 
toneum of  almost  cartilaginous  hardness.  Such  areas  of  indura- 
tion are  not  only  found  in  the  ileocecal  regiim  or  along  the  course 
of  the  colon,  but  also  in  Douglas'  fossa.  In  the  pelvis  these  indura- 
tions may  grow  to  actual  exudates  of  considerable  size,  which  in 
women  might  be  mistaken  for  diseased  adherent  ovaries  or  tuijer- 
cular  Fallopian  tubes. 

In  four  out  of  six  cases  operated  upon  by  Czerny  a  diagnosis 
of  probable  intestinal  tuberculosis  was  made  before  the  operation 
was  performed.  The  diagnosis  was  based  largely  upon  the  chnical 
histoiy,  which  indicated  the  existence  of  a  cicatricial  stenosis  in  the 
ileocecal  region ;  the  presence  of  a  swelHng  that,  on  percu.ssion, 
yielded  a  dull,  tympanitic  resonance,  and  that  was  movable  and  only 
slightly  tender  on  pressure ;  and  the  periodic  abdominal  pains 
cau.sed  by  exaggerated  intestinal  peristalsis,  as  described  by  Czerny, 
Konig,  and  Jienoit. 

The  anatomic  location  of  the  stricture  is  indicated  by  clhiical 
phenomena  that  deserve  careful  study  and  analysis.  Stenosis  of 
the  duodenum  above  the  entrance  of  the  bile-duct  gives  rise  to  the 
.same  .symptoms  as  .stenosis  of  the  pylorus,  but  below  this  point  it  is 
not  only  attended  by  symptoms  that  simulate  the  latter  affection, 
but  it  also  ob.structs  the  entrance  of  bile  into  the  intestinal  canal. 


940 


TUBERCULOSIS. 


The  most  important  condition  that  characterizes  duodenal 
stenosis  below  the  bile-duct  is  the  constant  presence  of  bile  in  the 
chyme  and  repeated  ejections  of  the  fluid  by  vomiting.  On  the 
other  hand,  in  three  clinical  observations,  Boas  showed  that  fluid 
taken  from  the  stomach  contained  not  only  bile,  but  also  pancreatic 
juice.  The  contents  of  the  stomach  possessed  all  the  chemic  prop- 
erties of  duodenal  chyme. 

Duodenal  differs  from  pyloric  obstruction  also  by  the  absence  of 
a  corresponding  dilatation  of  the  stomach,  by  the  absence  of  the 
products  of  fermentation  of  the  stomach-contents,  and  by  the  ab- 
sence of  sarcinee  and  yeast-cells.  No  distinction  can  be  made 
between  obstruction  in  the  lower  portion  of  the  duodenum  and  the 
upper  part  of  the  jejunum.  Vomiting  of  large  quantities  of  bile 
indicates  duodenal  obstruction,  while  the  ejected  material  assumes 
more  and  more  the  character  of  feces  the  lower  the  location  of  the 
obstruction.  In  eight  out  of  twelve  cases  of  duodenal  obstruction 
collected  by  Gerhardi  and  Hagenbach  the  disease  was  due  to  car- 
cinoma, cysts,  or  hemorrhage  of  the  pancreas.  The  search  for  the 
pancreatic  juice  in  the  stomach-contents  is  important.  A  number 
of  well-authenticated  cases  of  tuberculosis  of  the  duodenum  have 
been  placed  on  record,  and  there  is  no  reason  to  doubt  that  in  iso- 
lated cases  the  ulceration  might  heal  with  the  usual  remote  condi- 
tions following  cicatricial  stenosis  and  intestinal  obstruction.  If  the 
cicatricial  stenosis  involves  the  ileocecal  region  or  any  part  of  the 
colon,  the  usual  symptoms  indicative  of  intestinal  obstruction  in 
these  portions  of  the  intestinal  tract  will  develop.  Diarrhea  is  the 
most  constant  symptom  in  such  cases.  In  far-advanced  cases 
extensive  tympanites,  fecal  vomiting,  and  complete  interruption  of 
the  fecal  current  at  the  point  of  obstruction  complete  the  clinical 
picture  of  intestinal  obstruction. 

Diagnosis. — The  diagnosis  of  secondaiy  tuberculosis  of  the  in- 
testines presents  few  difficulties  if  the  primary  disease  is  well  marked 
and  if  the  organ  affected  is  readily  accessible  to  examination.  Pul- 
monary phthisis  generally  precedes  and  attends  secondary  intestinal 
tuberculosis.  In  women,  tuberculosis  of  the  internal  genital  organs 
occasionally  constitutes  the  primary  affection,  and  extension  takes 
place  to  the  intestinal  canal  either  through  the  lymphatic  channels 
or,  as  in  one  of  Czerny's  cases,  by  rupture  of  a  tubercular  abscess 
into  the  intestinal  canal.  In  cases  of  primary  intestinal  tuberculo- 
sis an  early  correct  diagnosis  is  seldom  made.  There  are  other 
ulcerative  affections  of  the  intestines  that  in  many  respects  resemble 
intestinal  tuberculosis.  Councilman  reports  a  case  of  extensive  and 
deep  ulceration  of  the  lower  portion  of  the  ileum,  complicated  by 
stricture  of  the  rectum,  which  terminated  in  death  from  perforation 
and  gangrenous  periproctitis,  and  in  which  typhoid  fever  and  tuber- 
culosis could  be  safely  excluded  as  causes.  At  the  postmortem, 
ulceration  of  the  ileum  was  found,  with  invasion  of  the  tissues  by 
colon  bacilli.      Some  of  the  ulcers  presented  the  appearance  of  an 


DIAGNOSIS. 


941 


acute  process ;  others  were  of  a  chronic  nature.  Numerous  bacteria, 
both  short  rods  and  micrococci,  were  found  in  the  superficial 
necrosed  tissue,  in  some  places  extending  into  the  cellular  infiltra- 
tion in  the  submucosa.  These  microbes  did  not  seem  to  stand  in 
any  direct  etiologic  connection  with  the  pathologic  changes.  I 
recently  had  under  observation  for  several  months  a  case  of  chronic 
diarrhea  that  had  resisted  all  remedial  measures.  The  patient  was 
a  man  about  thirty  years  of  age,  very  anemic  and  greatly  emaciated. 
No  hereditary  tendency  to  tuberculosis  and  no  cause  could  be  ascer- 
tained that  might  have  produced  the  chronic  intestinal  catarrh. 
Examination  of  the  lungs  and  other  important  organs  failed  to 
locate  a  tubercular  focus.  The  mesenteric  glands  could  not  be  felt 
on  palpation  and  rectal  examination.  The  stools  were  frequent  and 
liquid.  The  pain  was  slight  and  referred  to  the  umbilical  and 
hypogastric  regions. 

Intestinal  tuberculosis  was  suspected.  Carbonate  of  guaiacol 
and  salicylate  of  bismuth  were  administered  internall)',  and  the 
colon  was  washed  out  daily  with  a  copious  enema  of  warm  salt 
solution.  On  many  different  occasions  the  stools  were  examined 
for  tubercle  bacilli,  but  none  could  be  found.  Myriads  of  colon 
bacilli  and  micrococci  were  invariably  found.  The  absence  of 
tubercle  bacilli  in  the  stools  and  the  marked  improvement  that  fol- 
lowed the  treatment  leave  but  little  doubt  that  this  was  a  case  of 
intestinal  ulceration  caused  by  infection  with  the  colon  bacillus. 

Bacteriologic  examination  of  the  feces  in  suspected  cases  of 
intestinal  tuberculosis  should  never  be  neglected,  as  it  often  fur- 
nishes positive  proof  of  the  tubercular  nature  of  the  disease.  Tuber- 
cle bacilli,  when  present  in  the  feces,  in  which  they  may  be 
demonstrated  by  the  same  methods  as  in  sputum,  are  indicative  of 
intestinal  tuberculosis,  providing  that  they  are  observed  upon  repeated 
examination  and  that  clinical  .symptoms  are  present  that  point  to  the 
intestines  as  the  seat  of  disease,  as  otherwise  they  may  be  referable 
to  swallowed  tubercular  sputa. 

The  best  way  to  find  the  bacillus  is  to  dilute  the  feces  with  dis- 
tilled water  and  to  prepare  and  strain  the  deposit  after-  centrifuga- 
tion.  Sawyer  urges  the  importance,  in  cases  of  suspected  intestinal 
tuberculosis,  of  examining  the  mucus  collected  from  the  rectum, 
just  above  the  sphincter  ani,  for  bacilli.  When  found,  particularly 
on  the  surface  of  fissured  .stools,  the.se  clusters  of  bacilli  are  of 
diagnostic  value,  and  may  be  relied  on  to  indicate  tubercular  pro- 
cc-s.ses  ill  the  intestinal  tract.  He  has  thus  found  them  in  .several 
cases  when  they  could  not  be  found  in  the  sputum,  or  wiien  sputum 
could  not  be  obtained. 

If  the  tubercular  enteritis  has  progressed  to  thr  formation  of 
cicatricial  strictures,  the  differential  diagnosis  between  intestinal 
ob.struction  from  this  cause  and  other  inflanunatory  afn.-ctions  that 
result  in  ulceration  and  cicatricial  .stenosis  is  always  (liffuuit  and 
sometimes  impossible.      In   such   cases  a  probable  diagnosis  must 


942 


TUBERCULOSIS. 


rest  on  a  careful  study  of  the  clinical  history  and  search  for  tuber- 
cular foci  in  other  organs. 

Congenital  Stricture. — Congenital  stenosis  of  the  intestinal  canal 
may  appear  as  a  single  or  multiple  congenital  defect,  may  affect  any 
portion  of  the  intestinal  canal,  and  may  cause  no  symptoms  until 
long  after  birth.  Intestinal  stricture  occurring  in  infants,  children, 
and  young  adults,  without  any  history  of  the  existence  of  an  ante- 
cedent ulcerative  lesion,  is  quite  frequently  of  a  congenital  origin. 

Traumatic  Stricture. — If,  in  cases  of  intestinal  obstruction  from 
a  stricture,  the  clinical  history  shows  that  the  patient  has  been  the 
subject,  in  the  past,  of  an  injury  to  the  abdomen,  it  should  be  borne 
in  mind  that  the  stricture  may  be  the  direct  result  of  the  trauma. 
Such  strictures  are  occasionally  caused  by  a  blow  on  the  abdomen. 
Mygind  reports  such  a  case.  Intestinal  resection  was  performed, 
six  months  after  the  accident,  for  symptoms  of  obstruction,  and  the 
patient  recovered. 

Traumatic  strictures  may  result  from  laceration  of  the  mucosa  or 
from  plastic  peritonitis.  In  the  former  variety  the  lesion  of  the 
mucous  membrane  would  be  likely  to  simulate  more  closely  tuber- 
cular enteritis  than  the  peritonitic  form.  In  both  instances,  how- 
ever, the  catarrhal  enteritis  complicating  the  chronic  obstruction 
would  present  some  clinical  features  in  common  with  tubercular 
enteritis. 

Stricture  Following  Strangulated  Hernia. — It  has  been  known 
for  a  number  of  years  that  intestinal  stricture  occasionally  develops 
after  the  reduction  of  a  hernia  by  taxis  or  operation.  The  stricture 
is  such  cases  is  caused  by  a  circular  necrosis  of  the  mucous  mem- 
brane, resulting  from  the  pressure  by  the  strangulation.  The  elimi- 
nation of  the  necrosed  tissue  is  followed  by  ulceration,  and  the 
healing  of  the  circular  ulcer  finally  leads  to  cicatricial  contraction 
and  intestinal  stenosis.  Garre  first  described  intestinal  stricture  as 
one  of  the  remote  results  of  a  strangulated  hernia.  He  made  the 
observation  that  in  some  cases  of  strangulated  hernia  the  mucous 
membrane  of  the  bowel  at  the  point  of  constriction  becomes  ne- 
crotic and  is  cast  off  as  a  slough.  The  circular  defect  heals  by 
granulation,  and  the  resulting  scar  leads  to  circular  constriction. 

In  his  first  case  the  symptoms  of  obstruction  necessitated  a 
laparotomy,  which  was  performed  nine  weeks  after  the  herniotomy. 
The  patient  was  twenty-seven  years  old,  and  the  subject  of  a  pre- 
peritoneal inguinal  hernia.  Intestinal  resection  to  the  extent  of 
forty-one  centimeters  was  made,  and  the  continuity  of  the  bowel 
restored  by  circular  enterorrhaphy.  The  patient  recovered.  Exam- 
ination of  the  specimen  removed  showed  that  the  ulcerated  surface 
had  not  entirely  healed.  At  one  point  the  ulceration  extended  as 
far  as  the  peritoneum. 

Ravult  reports  a  case  of  double  cicatricial  stricture  of  the  small 
intestine  that  caused  death  from  acute  intestinal  obstruction.  Sev- 
eral years  before  the  last  illness  the  patient  was  operated  upon  sue- 


OVARIAN    TUMOR.  ^,, 

943 

cessfully  for  strangulated  hernia.      The  acute  attack  of  intestinal 
obstruction  resulted  fatally  in  a  k.v  days.     The  necropsy  re  ealed 
vvo  strictures  eight  centimeters  apart;  the  segment  of  bowel  be- 
tween  them  was  distended  by  gas.      Above  the  stricture  on  the 
proximal  side  the  bowel  was  greatly  distended  and  vascular  while 
the  intestine  below  the  second  stricture  was  contracted.  emptV   and 
pale.      The  strictures  were    undoubtedly  the    result  of  slm^riiincx 
ulceration,   and  scar  formation,   consecutive  pathologic   conditions 
caused   by  harmful   cnxular   constriction   by  the  neck  of  the  her 
nial  sac.    The  time  of  appearance  of  symptoms  of  obstruction  in  this 
form  of  intestinal  stenosis  varies  from  a  few  davs  to  a  year  or  more 
t;itt  records  a  case  of  femoral  hernia  in  which  symptoms  of  obstruc- 
tion  appeared   five   days   after  the  reduction   of   the   strangulated 
hernia,  while  in  Garre's  case  the  symptoms  of  obstruction  did  not 
set  in  until  nine  weeks  after  the  relief  of  the  strangulation  by  taxis 
Ihe  possibility  of  the  existence  of  a  cicatricial  stricture  due  to 
such  a  cause  mu.st  be  remembered  in  cases  of  intestinal  obstruction 
in  which  the  clinical  history  refers  to  strangulated  hernia  relieved 
either  by  taxis  or  operation. 

Strictior  Follcnving  Healing  of  Typhoid  Ulcer.— Th^  healincr  of 
typhoid  ulcers  is  very  rarely  followed  by  cicatricial  stenosis  Treves 
made  a  very  careful  search  for  stricture  of  the  intestine  caused  by 
typhoid  ulcer,  and  was  able  to  find  only  one  well-authenticated 
case.  Typhoid  ulcers,  as  a  rule,  heal  rapidly,  and  much  of  the 
tissue  destroyed  is  reproduced  by  the  reparative  process,  leavino- 
only  a  minimum  quantity  of  connective  tissue,  while  the  healino-  of 
a  tubercular  ulcer  is  attended  by  the  formation  of  an  abundancS  of 
connective  tissue  that  subsequently  undergoes  progressive  cicatricial 
contraction.  The  locations  for  the  stricture  are  the  same  in  typhoid 
and  tubercular  ulcers. 

Syphilitic    Stricture.— Amonir    the    multiform    visceral     lesions 
cau.sed  by  tertiary  syphilis  are   to    be   noted   intestinal   strictures 
According  to  Rieder,  the  lesions  causing  the  obstruction  are  most 
frequently   met    with    in    the    upper    part  of  the    small    intestine, 
byphihtic  stricture  is  not  caused  by  ulceration,  but  by  the  produc- 
tion of  new  connective  tissue  in   the  submucosa  and   later  in   the 
other  coats.      The  symptoms  attending  syphilitic  intestinal  stricture 
indicate  the  existence  of  a  mechanical  obstruction  without  the  exist- 
ence of  a  previous  ulceration,  as  is  the  case  in  tubercular  stricture. 
Ovarian  Tumor.— The  differential  diagnosis  between  a  tubercu- 
lar stricture  and  intestinal  obstruction  caused  by  certain  anatomico- 
pathologic  forms  of  ovarian  tumor  is  attended  by  many  difficulties. 
In  one  of  Czerny's  cases  of  ileocecal   tubcrculo.sis  the  swelling  was 
mistaken  for  an  ovarian  tumor  by  the  attending  phy.sician.      Veit 
has  .shown  that  in  women  the  differential  diagnosis  between  tuber- 
culosis of  the  ileocecal   portion  of  the  intestinal   tract  and  ovarian 
tumor  that  has  extended  to  the  mescjcecum  and  mesocolon  i.s  always 
extremely  difficult  and  often  impossible. 


944 


TUBERCULOSIS. 


Malignant  Stncture. — The  two  causes  that  give  rise  to  intestinal 
obstructions  most  likely  to  be  mistaken  for  each  other  are  cicatricial 
stenosis  following  tubercular  ulcer  and  malignant  stricture.  The 
ileocecal  region  is  the  favorite  locality  for  both  of  these  affections. 
In  intestinal  obstruction  due  to  either  of  these  causes  the  clinical 
history  is  characterized  by  a  complexus  of  symptoms  pointing  to 
chronic  obstruction,  and  in  either  case  involvement  of  the  mesen- 
teric and  retroperitoneal  lymphatic  glands  is  sure  to  occur  sooner 
or  later.  Tubercular  strictures  are  found  most  frequently  in  persons 
below  middle  age,  while  carcinoma  is  more  likely  to  occur  in  persons 
of  advanced  age.  The  reverse  may,  however,  be  the  case,  as  intes- 
tinal tuberculosis  may  attack  the  aged,  and  intestinal  carcinoma 
may  occur  in  young  adults.  The  detection  of  a  tubercular  focus  in 
another  organ  and  the  discovery  of  tubercle  bacilli  in  the  stools 
will  furnish  evidences  of  the  tubercular  nature  of  the  obstructive 
lesion,  and  will  exclude  the  probability  of  the  existence  of  malignant 
disease. 

Surgical  Treatment. — The  foregoing  heading  may  appear  some- 
what strange  and  out  of  place  to  the  general  practitioner  and  the 
surgeon  who  have  not  kept  fully  abreast  with  the  great  advance- 
ments that  have  been  made  during  the  last  decade  in  the  diagnosis 
and  surgical  treatment  of  localized  lesions  of  the  intestinal  tract. 
Our  increased  knowledge  of  the  location,  nature,  and  clinical  ten- 
dencies of  accessible  tubercular  affections  has  opened  a  wide  and 
fertile  field  for  successful  surgical  intervention.  There  is  hardly  an 
organ  in  the  body  that,  when  the  seat  of  a  localized  tubercular  pro- 
cess, has  not  been  exposed  and  subjected  to  direct  treatment  with  a 
fair  expectation  of  removing  or  limiting  the  further  extension  of  the 
disease.  The  medical  treatment  of  tuberculosis  in  its  various  forms 
at  the  present  time  is  not  much  in  advance  of  that  of  fifty  years  ago. 
The  numerous  specifics  invented  and  vaunted  in  different  parts  of 
the  world  have  all  fallen  by  the  wayside,  and  the  old-fashioned  rem- 
edies are  again  taking  their  place.  Leaving  out  the  local  measures, 
we  have  to  rely,  in  the  treatment  of  such  cases,  largely  on  diet, 
change  of  climate  and  occupation,  outdoor  air,  and  the  administra- 
tion of  those  remedies  known  to  exercise  a  favorable  influence  in 
improving  digestion,  nutrition,  and  assimilation,  and  thus  indirectly 
antagonize  the  ravages  of  the  disease. 

Powerless  as  we  remain  to-day  in  the  successful  systemic  treat- 
ment of  tuberculosis,  it  is  a  source  of  gratification  to  know  that  great 
improvements  have  been  made  in  the  local  treatment  of  accessible 
tubercular  lesions.  The  intestinal  canal  is  one  of  the  last  territories 
opened  up  for  successful  surgical  invasion.  All  the  work  done  in 
this  department  of  surgery  dates  back  but  a  few  years.  The  re- 
sults obtained  by  the  surgical  treatment  of  localized  intestinal  tuber- 
culosis are  such  as  to  encourage  further  efforts  in  this  direction. 
The  number  of  cases  operated  upon  so  far  remains  a  small  one,  and 
it  is  my  intention  to  bring  these  cases  to  the  attention  of  the  pro- 


ABDOMINAL    SECTION    AND    lODOFORMIZATION.  945 

fession  of  this  country  and  to  describe  the  different  operative  pro- 
cedures that  have  been  employed  by  different  operators  with  the 
same  aim  in  view — to  remove  the  diseased  tissue,  or  to  render 
the  affected  portion  of  the  bowel  accessible  to  direct  treatment,  or 
to  place  it  in  a  more  favorable  condition  for  the  spontaneous  healing 
of  the  tubercular  ulcers. 

The  remarks  will  be  limited  to  localized  primary  tuberculosis  of 
the  intestinal  canal,  illustrated  by  cases  amenable  to  successful  sur- 
gical treatment.  Diffuse  primary  tuberculosis  of  the  intestines  re- 
mains, for  the  present,  a  surgical  )ioli  mc  tangcrc.  Surgical  inter- 
vention is  also  contraindicated  in  secondary  intestinal  tuberculosis 
in  all  cases  in  which  the  primary  disease,  usually  pulmonarx'  tuber- 
culosis, is  far  advanced  and  constitutes  in  itself  an  imminent  source 
of  danger  to  life.  There  are,  however,  cases  of  primary  intestinal 
tuberculosis  in  which  timely  radical  measures  prove  successful  in 
eliminating  the  disease  permanently  and  in  restoring  normal  intesti- 
nal digestion  and  absorption.  The  attention  of  the  mass  of  the  pro- 
fession must  be  called  to  the  necessity  of  a  more  careful  and  thor- 
ough examination  of  chronic  inflammatory  affections  of  the  intestinal 
tract,  for  the  purpose  of  making  an  early  and  correct  diagnosis,  and 
with  a  view  to  selecting  appropriate  cases  for  timely  surgical  treat- 
ment. The  internist  and  the  surgeon  must  cooperate  with  each 
other  in  the  future  development  of  this,  one  of  the  most  recent  de- 
partments of  successful  surgical  interv^ention. 

The  cases  operated  upon  for  intestinal  tuberculosis  will  be  re- 
ferred to  under  the  headings  of  the  different  operative  procedures  : 

/.  Abdovwial  Section  and  lodofonnizatuvi. — Every  surgeon  is 
familiar  with  the  curative  effects  of  abdominal  section  and  drainage, 
with  or  without  iodoformization,  in  cases  of  peritoneal  tuberculosis. 
The  modus  operandi  of  this  method  of  treatment  has  never  been  fully 
and  satisfactorily  explained,  but  the  fact  remains  that  it  has  proved 
eminently  successful  in  the  majority  of  such  cases.  There  can  be 
but  little  doubt  that  the  local  application  of  iodoform  adds  to  the 
therapeutic  value  of  this  method  of  treatment.  In  one  of  the  cases 
that  recently  came  under  my  observation  abdominal  section  and 
drainage  were  resorted  to  on  two  different  occa.sions,  but  the  tuber- 
cular hydrops  returned.  Tapping  and  the  injection  of  from  two  to 
four  drams  of  a  10  per  cent,  iodoform-glycerin  emulsion,  repeated 
six  or  eight  times  at  intervals  of  from  one  to  two  weeks,  finally  suc- 
ceeded in  effecting  a  cure,  and  the  patient  was  in  perfect  health  when 
la.st  .seen,  more  than  a  year  after  the  last  tapping.  Future  observa- 
tions will  undoubted!}'  prove  that  peritoneal  tuberculosis  is  more 
frequently  caused  by  infection  innw  primary  intestinal  lesions  than 
has  been  heretofore  supposed. 

It  is  not  strange  that  the  .same  treatment  shcnild  occa.sionally 

prove  equally  u.seful  and  efficient  in  certain  ca.ses  of  intestinal  as  in 

peritoneal  tuberculosis.      Nove-Josseraud  made  a  laparotomy  on  a 

child  twelve  years  old  for  a  swelling  the  .size  of  an  adult's  fi.st  in 

60 


946  '  TUBERCULOSIS. 

the  region  of  the  cecum.  The  incision  demonstrated  the  existence 
of  extensive  tuberculosis  of  the  cecum  and  adjacent  portions  of  the 
ileum  and  ascending  colon.  The  affected  parts  were  not  interfered 
with,  except  that  they  were  wiped  gently  with  iodoform  gauze  and 
dusted  with  a  thin  film  of  iodoform,  and  yet  the  operation  was  fol- 
lowed by  a  speedy  and  permanent  recovery. 

This  method  has  a  limited  application  in  the  treatment  of  intes- 
tinal tuberculosis  when  the  disease  is  too  extensive  for  more  radi- 
cal measures  and  no  obstructive  lesion  is  indicated  by  the  symptoms 
or  discovered  at  the  time  of  operation.  lodoformization  and  capil- 
lary drainage  with  iodoform  gauze  for  a  few  days  would  seem  to 
be  indicated  in  such  cases. 

2.  Enteroplasty . — Plastic  operations  are  indicated  in  solitary  cir- 
cular strictures  following  the  healing  of  a  tubercular  ulcer  and  con- 
stituting the  cause  of  intestinal  obstruction.  In  narrow  circular 
strictures  an  operation  similar  to  that  devised  by  Heineke-Mikulicz 
for  pyloric  cicatricial  stenosis  will  yield  the  most  satisfactory  opera- 
tive and  functional  results.  The  stricture  is  divided  on  the  convex 
side  of  the  bowel  and  the  incision  carried  sufficiently  far  into 
healthy  tissues  on  each  side  of  the  stricture,  in  a  direction  parallel 
to  the  long  axis  of  the  bowel,  and  the  visceral  wound  closed  trans- 
versely by  two  rows  of  sutures  of  fine  braided  silk,  thus  restoring 
the  lumen  of  the  bowel  to  its  normal  size.  The  operation  is  a 
plastic  one,  using  healthy  tissue  from  both  sides  of  the  stricture, 
with  which  the  lumen  of  the  bowel  is  restored  to  its  physiologic  re- 
quirements. As  the  sutures  have  to  overcome  considerable  resist- 
ance in  closing  the  wound,  they  should  be  inserted  and  tied  from 
each  angle  of  the  wound  toward  the  center,  and  at  least  two  rows 
are  required.  If  much  tension  on  the  sutures  is  anticipated,  the 
quilt  suture  of  Halsted  should  be  relied  upon  for  the  outer  or  sero- 
muscular sutures. 

Pean  performed  such  an  operation  for  cicatricial  stenosis  of  the 
ileocecal  valve  following  the  healing  of  a  tubercular  ulcer.  He 
made  the  abdominal  incision  above  and  parallel  to  Poupart's  liga- 
ment. The  bowel  was  tied  above  and  below  the  constriction  with 
a  rubber  cord  passed  through  a  slit  in  the  mesentery.  The  intes- 
tinal wall  was  incised  at  the  level  of  and  at  each  side  of  the  stric- 
tured  valve  for  a  distance  of  three  inches.  After  washing  out  the 
opened  segment  of  the  bowel  with  a  i  per  cent,  solution  of  car- 
bolic acid,  the  cicatricial  tissue  was  excised.  This  beine  done, 
the  two  extremities  of  the  intestinal  wound  were  brought  together 
by  means  of  forceps.  The  incision,  which  was  first  longitudinal, 
soon  took  the  form  of  a  lozenge,  two  sides  of  which  were  repre- 
sented by  the  edges  of  the  small  intestine,  and  the  other  two  by  those 
of  the  large  intestine.  Bringing  the  forceps  nearer  together  the 
incision  became  transverse,  and  in  this  position  the  edges  were 
sutured  in  the  usual  way.  The  patient  recovered  and  remained  in 
good  health  at  the  time  the  report  was  made. 


ENTERECTOMY.  947 

J.  Enterectomy. — The  most  radical  treatment  of  intestinal  tuber- 
culosis, in  appropriate  cases,  is  resection,  followed  by  circular 
suturing.  Resection  is  indicated  in  isolated  intestinal  tuberculosis 
as  long  as  the  swelling  is  movable  and  the  disease  gives  rise  to 
symptoms  of  obstruction ;  if,  however,  the  disease  is  no  longer 
limited  to  the  organ  primarily  affected,  or  if  it  is  complicated  by 
advanced  pulmonary  or  general  tuberculosis,  entero-anastomosis 
should  take  the  place  of  a  radical  operation.  Experience  has  shown 
that  it  is  neither  essential  nor  even  necessary  to  add  to  the  gravity 
of  the  operation  b)-  attempts  to  remove  the  products  of  regional 
infection.  After  removal  of  the  primar)-  focus  of  infection  the 
lymphatic  tuberculosis  usually  comes  to  a  standstill,  although  cases 
ha\e  been  recorded  in  which  later  reinfections  occurred  from  this 
source. 

Diffuse  glandular  tuberculosis  in  such  cases  is  beyond  the  reach 
of  safe  surgery.  Caseous  glands  in  the  mesentery,  corresponding 
with  the  portion  of  the  intestine  excised,  should  be  removed  by 
including  the  mesentery  in  the  excision.  So  far  excision  has  been 
performed  only  in  cases  in  which  the  tubercular  lesion  gave  rise 
to  intestinal  obstruction.  The  results  of  this  operation  will  be 
greatly  improved  in  the  future  when  intestinal  resection  will  be  per- 
formed as  soon  as  a  localized  tubercular  lesion  can  be  diagnosticated, 
and  before  the  patient's  general  condition  has  been  seriously  impaired 
by  the  mechanical  obstruction. 

Intestinal  resection  has  been  most  frequently  performed  for 
tuberculosis  in  the  ileocecal  region.  A  number  of  cases,  however, 
have  been  recorded  in  which  the  seat  of  the  disease  was  the  small 
intestine.  Dr.  Rudolph  Matas  made  a  successful  enterectomy 
for  intestinal  stricture  following  the  healing  of  a  tubercular  ulcer 
involving  the  upper  portion  of  the  jejunum.  The  patient  made  a 
rapid  and  permanent  recovery  (personal  communication). 

Konig  reports  five  cases  of  stricture  of  the  intestine  caused 
by  cicatricial  contraction  of  tubercular  ulceration,  all  treated  by 
laparotomy  and  resection  of  the  intestine,  with  circular  enterorrhaphy. 
Two  of  the  patients  died  :  one  from  exhaustion,  the  other  from  the 
giving  way  of  a  suture,  an  accident  that  resulted  in  leakage  and 
diffuse  peritonitis.  He  believes  that  tliis  pathologic  form  of  cicatri- 
cial stenosis  is  much  more  frequent  and  more  easily  recogni/.etl  than 
has  hitherto  been  thought.  He  has  met  with  this  affection  mo.st 
frequently  in  persons  between  twenty  and  thirty  years  of  age,  and 
especially  in  tlio.se  suffering  from  other  tubercular  lesions.  Me  has 
made  a  careful  investigation  of  such  ca.ses  and  found  that  the  clin- 
ical hi.story  usually  reveals  a  chronic  cau.se,  frecjuent  attacks  of 
colic  with  constipation,  tympanites,  vi.sible  peristalsis,  and  peculiar 
splashing  and  musical  sounds,  ending  with  a  sound  that  resembles 
that  of  fluid  driven  forcibly  from  a  .syringe.  The  di.sea.se  invariably 
produces  great  emaciation  and  anenna.  In  spite  of  the  feebleness 
of  the   patients,  Konig   thinks  surgical   interference  advisable,  espc- 


948  TUBERCULOSIS. 

cially  as  the  ulceration  is  probably  still  progressing  in  part  of  the 
cicatricial  contraction,  and  often  the  tubercular  disease  elsewhere  is 
not  far  advanced. 

Treves  made  a  resection  of  the  intestine  for  tubercular  stricture, 
and  united  the  bowel-ends  by  the  use  of  Murphy's  button.  The 
patient  made  a  satisfactory  recovery. 

Sachs  reports  the  following  case  of  resection  for  intestinal  tuber- 
culosis :  A  woman,  aged  forty-one,  had  suffered  for  a  long  time 
from  constipation,  and  for  two  years  had  had  loss  of  appetite  and 
gradually  increasing  marasmus  and  debility.  On  examination  a 
hydronephrosis  of  the  right  kidney  was  discovered,  and  also  a 
swelUng  in  the  right  iliac  fossa,  which  was  supposed  to  be  of  a 
malignant  nature.  Laparotomy  was  performed,  when  the  right  iliac 
fossa  was  found  to  be  occupied  by  a  hard  swelling  the  size  of  an 
adult's  fist.  Surrounding  the  ileum  was  a  band  of  contracted 
fibrous  tissue  with  tubercular  granulations  in  some  places.  The 
diseased  parts  were  resected,  and  the  two  ends  of  the  intestine 
joined  together  by  circular  enterorrhaphy.  The  patient  recovered 
and  was  in  a  satisfactory  condition  several  weeks  after  the  opera- 
tion. On  examination  of  the  specimen  removed  the  ileum  was  seen 
to  be  surrounded  by  a  band  of  scar  tissue  and  granulations.  At 
the  junction  of  the  ileum  with  the  cecum  there  was  a  large  tuber- 
cular mass  that  extended  to  the  mesenteric  glands.  The  mucous 
membrane  of  the  cecum  was  replaced  by  tubercular  granulations 
that  extended  into  the  muscular  coat,  and  on  microscopic  examina- 
tion were  seen  to  consist  of  epithelioid  and  giant  cells.  He  collected 
thirteen  cases  of  resection  of  the  ileocecal  portion  of  the  intestinal 
canal  for  tuberculosis,  of  which  eleven  recovered. 

Zahlmann  reports  a  case  of  tubercular  stricture  of  the  intestines 
removed  by  Tage  Hansen,  of  Denmark.  The  patient,  a  girl  aged 
seventeen  years,  had  been  previously  treated  for  tuberculosis  of  the 
phalanges  of  the  fingers  and  toes.  For  one  and  a  half  years  she 
had  exhibited  signs  of  stricture  of  the  intestines,  and  at  the  laparot- 
omy the  entire  cecum,  with  the  adjacent  parts  of  the  ascending  colon 
and  ileum,  were  found  to  be  the  seat  of  an  inflammatory  mass  that 
had  produced  a  stricture  an  inch  and  a  half  in  length,  of  a  diameter 
corresponding  to  that  of  a  lead-pencil,  while  the  walls  were  nearly 
an  inch  in  thickness.  Six  inches  of  the  ileum,  the  entire  cecum, 
and  four  inches  of  the  ascending  colon  were  removed.  The  healthy 
ends  of  the  ileum  and  colon  were  united  by  means  of  Lembert 
sutures,  the  difficulty  in  adapting  the  different  lumina  to  each  other 
being  overcome  by  dividing  the  ileum  by  an  oblique  section  at  the 
expense  of  the  convex  side.  The  patient  recovered  and  remained 
in  good  health  at  the  time  the  report  was  made,  six  months  after  the 
operation. 

Of  five  cases  of  intestinal  tuberculosis  in  which  the  cecum  and 
colon  were  the  seat  of  disease,  and  in  which  Czerny  resorted  to 
resection  and  circular  suturing,  two  died  of  peritonitis  and  one  of 


ENTERECTOMV. 


949 


hemoptysis  after  complete  recovery  from  the  operation.  In  one  case 
the  peritonitis  was  caused  by  leakage  through  one  of  the  needle 
punctures,  and  in  the  second  the  perforation  occurred  in  consequence 
of  abscess  formation  in  the  line  of  suturing.  The  patient  died  from 
the  effects  of  peritonitis,  septicopyemia,  and  metastasis  five  weeks 
after  the  operation.  In  one  case  the  operation  proved  successful, 
but  was  followed  by  rapid  generalization  of  the  tubercular  process, 
an  obser\-ation  fully  corroborated  by  Wahllandcr  and  Wolff,  who 
have  called  special  attention  to  the  diffusion  of  tubercular  processes 
after  intervention  for  what  appeared  as  localized  affections.  In  one 
case  of  secondary  tuberculosis  following  rupture  of  a  tubercular 
adnexal  abscess  into  the  intestine  circular  suturing  after  excision 
was  found  impossible,  and  consequently  an  artificial  anus  was 
established,  with  an  excellent  functional  result.  Among  the  cases 
operated  upon  by  Czerny  and  reported  by  Rindfleisch  are  several 
in  which  the  remote  results  of  operations  for  intestinal  tubercu- 
losis have  since  been  ascertained.  In  the  case  of  a  woman  thirty- 
four  j'ears  of  age,  operated  upon  in  1886,  nothing  definite  could  be 
learned  as  to  the  subsequent  history.  In  the  case  of  an  ileocecal 
resection  performed  in  1888  on  a  man  thirty  years  of  age,  death 
resulted  three  years  later  from  pulmonaiy  tuberculosis.  The  post- 
mortem revealed  tubercular  ulcers  in  the  colon  and  small  intestine, 
with  miliary  tubercles  on  the  peritoneal  surface,  and  cheesy  mesen- 
teric glands.  No  information  could  be  had  in  the  case  of  a  man 
fifty-four  years  of  age,  subjected  to  ileocecal  resection,  but  the 
operation  appeared  to  have  exerted  no  influence  in  checking  the 
progress  of  the  pulmonary  affection.  A  man  twenty-six  }'ears  of 
age  died  of  pulmonary  tuberculosis  two  years  after  tiie  operation. 
A  woman  twenty-two  years  of  age  was  in  good  health  four  years 
after  the  operation.  A  man  thirty-one  years  of  age  was  found  in 
excellent  health  four  years  after  the  operation,  having  gained  during 
this  time  twent\'-three  pounds  in  weight.  This  jxitient  suffered  only 
occasionally  from  catarrh  of  the  colon,  the  attacks  being  of  short 
duration.  The.se  cases  go  to  prove  that  re.section  for  intestinal 
tuberculosis  in  well-selected  cases  yields  satisfactory  remote  results, 
while  the  reverse  is  true  if  the  operation  is  performed  under  adverse 
conditions. 

Rentier  resected  the  entire  cecum  for  tuberculosis,  ami  united 
the  bowel-ends  by  means  of  Murphy's  button.  Death  occurred  on 
the  .sixth  day  after  the  operation.  The  lumen  of  the  button,  which 
remained  in  situ,  was  completely  blocked  by  feces.  Additic^nal 
tubercular  ulcers  were  found  in  the  jejunum. 

Caminiti-Vinci  reports  the  case  cjf  a  man  aged  twenty-four,  with- 
out any  tubercular  family  history,  who  for  the  la.st  nine  months  had 
suffered  from  .severe  pain  in  the  left  sujjcrior  quadrant  of  the  abdo- 
men, aggravated  after  meals  ;  no  (harrhea  or  vomiting.  In  the 
affected  region  an  ill-defined  swelling  couM  he  felt,  descending 
slightly   with   in.spirati<jn,   and   mtluM-   painful    on    palpation.      Ihc 


950  TUBERCULOSIS. 

patient  not  improving  under  medical  treatment,  was  operated  upon 
March  8,  1896.  The  omentum  was  found  thickened,  hard,  and 
adherent  to  the  small  intestine  for  about  ten  centimeters  ;  this  was 
excised,  as  were  also  about  thirty  centimeters  of  the  intestine  itself, 
with  its  mesentery  and  glands.  The  bowel  was  united  by  circular 
suturing.  The  patient  recovered  and  remained  in  good  health  four 
months  after  the  operation.  Macroscopic  and  microscopic  exami- 
nation proved  the  tubercular  nature  of  the  disease  in  the  parts 
removed. 

Courtillier  reports  the  case  of  a  boy  twelve  years  of  age  oper- 
ated upon  by  Broca  for  tuberculosis  of  the  cecum.  The  entire 
cecum  was  resected  and  the  ileum  united  with  the  ascending  colon 
by  circular  suturing.  The  patient  recovered  from  the  operation  and 
remained  in  perfect  health  for  three  years,  when  a  fecal  fistula  ap- 
peared at  the  site  of  operation.  Operation  for  closure  of  the 
fistula  was  followed  by  death.  The  autopsy  showed  the  small 
intestine  in  a  perfectly  healthy  condition,  but  the  disease  had  reached 
the  ascending  colon  and  was  complicated  by  tuberculosis  of  the 
left  lung. 

Durante  has  resected  the  cecum  for  tuberculosis  five  times.  He 
calls  attention  to  the  difficulties  presented  relative  to  making  an 
early  diagnosis.  Intermittent  diarrhea  for  from  two  to  six  years  is 
a  conspicuous  and  almost  constant  symptom.  For  a  long  time  the 
general  health  is  not  much  impaired.  Symptoms  of  progressive 
cicatricial  stenosis  finally  appear.  In  one  case  he  was  able  to  ascer- 
tain from  examination  of  the  specimen  that  the  tubercular  process 
had  its  primary  starting-point  in  the  appendix.  Of  the  five  cases, 
four  lived  and  were  in  good  health  from  five  to  seven  years  after  the 
operation.  In  one  case  relapse  was  due  to  incomplete  removal  of 
the  infected  tissues.  He  regards  the  prognosis  as  favorable  after 
complete  extirpation  of  the  affected  portion  of  the  intestine. 

Emil  Miiller  resorted  to  resection  in  two  cases  of  tubercular 
stricture  of  the  intestine.  In  the  first  case  the  disease  extended 
over  the  lower  part  of  the  ileum,  cecum,  and  ascending  colon,  to 
within  an  inch  of  the  right  colic  flexure.  In  the  second  case  the 
operation  was  performed  extraperitoneally.  After  opening  the 
abdomen  by  lateral  incision  the  colon  was  made  movable  by  excis- 
ing the  external  layer  of  the  mesocolon,  when  the  diseased  portion 
of  the  intestine  was  brought  forward  into  the  wound.  The  inner 
layer  of  the  mesocolon  was  sutured  to  the  inner  margin  of  the 
incision,  and  the  peritoneal  cavity  on  the  outer  side  of  the  bowel 
was  shut  out  with  an  iodoform  gauze  tampon.  After  six  days  the 
affected  portion  of  the  intestine  was  extirpated  extraperitoneally. 
The  continuity  of  the  intestinal  canal  was  restored  by  circular 
suturing,  which  could  be  done  Avithout  invading  the  excluded  peri- 
toneal cavity.  The  external  wound  was  sutured  and  drained.  The 
patient  recovered  rapidly  without  any  untoward  symptoms,  and  was 
discharged  from  the  hospital  with  his  health  restored. 


TUBERCULOSIS    OF    THE    CECUM    AND    ILEUM.  95 1 

To  what  extent  operative  procedure  can  be  carried  with  ultimate 
recovery  in  true  cases  of  intestinal  tuberculosis  is  well  shown  bv  a 
case  reported  by  Korte.  The  patient,  a  man  twenty-five  years  of 
age,  was  operated  upon  in  1891  for  acute  suppurative  peritonitis. 
The  following  year,  March  i6th,  the  appendix  was  removed.  In 
August  of  the  same  year  a  swelling  developed  along  the  course  of 
the  cecum  and  ascending  colon.  August  27th  the  cecum  and 
ascending  colon,  nearly  as  far  as  the  hepatic  flexure,  were  excised. 
Healthy  tissue  was  not  reached.  An  artificial  anus  was  established. 
The  microscope  demonstrated  the  tubercular  nature  of  the  intes- 
tinal affection.  The  enterotome  was  used  without  any  benefit. 
In  November  twenty-one  centimeters  of  the  colon  were  resected. 
The  end  of  the  colon  was  invaginated  and  sutured,  and  an 
entero-anastomosis  established  between  the  colon  and  the  lower 
portion  of  the  ileum.  A  fecal  fistula  followed  the  operation.  In 
Februaiy,  1893,  Dieffenbach's  enteroplasty  was  performed,  but 
proved  unsuccessful.  In  May  a  loop  of  the  small  intestine  was 
implanted  into  the  sigmoid  flexure.  For  two  weeks  there  were 
normal  evacuations  per  rectum ;  then  a  fecal  fistula  formed.  July  3d 
what  was  left  of  the  colon  was  permanently  and  completely 
excluded  by  closing  both  ends.  Regular  evacuations  by  rectum 
followed.  July  23d  the  excluded  colon  was  resected.  Patient 
recovered.  Subsequent  treatment  was  with  iodoform  gauze  pack- 
ing. The  fecal  discharge  from  the  fistula  was  always  liquid,  but  as 
soon  as  it  passed  through  what  remained  of  the  colon  the  stools 
became  natural.  Only  one  case  of  resection  for  intestinal  tubercu- 
losis has  come  under  my  own  observation. 

Tuhercidosis  of  the  Cecum  and  Ileum. — Resection  of  cecum  and  eighteen  inches  of 
the  ileum  with  corresponding  portion  of  mesentery.  Restoration  of  continuity  of  intes- 
tinal canal  by  lateral  anastomosis  with  the  aid  of  decalcified  bone-j^latt's.  Recovery  ; 
return  of  the  intestinal  affection,  and  death  six  months  after  operation.  The  |ialicnt  was 
a  spare  man  of  medium  height,  thirty-seven  years  of  age,  and  a  fanner  by  occupation. 
He  was  unaware  of  the  existence  of  any  hereditary  taint  or  predis|)osition  to  tuberculosis 
or  malignant  disease  in  the  family.  His  health  was  excellent  prior  to  August  16,  1887. 
On  that  day  he  was  taken  suddenly  ill  with  an  attack  of  vomiting,  without  any  obvious 
cause,  which  lasted  for  six  hours.  The  patient  insisted  that  toward  the  last  he  vomited 
fecal  matter.  He  recovered  rapidly  and  remained  in  comparatively  good  health  until  the 
following  October,  when  he  suffered  from  a  similar  attack  of  four  hours'  dination.  This 
time  he  exjjerienced  a  sharp  |3ain  in  the  ileocecal  region,  and  soon  after  felt  a  distinct 
swelling  in  that  locality.  From  this  time  on  until  March,  1889,  the  i)ain  recurred  peri- 
odically, the  intervals  becoming  shorter,  until  pain  became  almost  continuous,  with  few 
and  incomplete  remissions.  During  this  time  he  suffered  also  a  great  deal  from  (lalulence. 
The  bowels  were  inclined  to  be  loose,  but  the  general  health  was  not  seriously  impaired. 
Since  March,  1889,  diarrhea  became  a  prominent  symptom,  the  stools  being  lii|ui(l,  but 
showing  no  trace  of  blood  or  mucus.  Pain  increased  in  severity  and  was  more  conslnnt,  ancl 
was  always  jjartially  relieved  by  the  free  escape  of  gas  per  rectum.  At  the  time  he  entered 
the  hospital  (October  9,  1889)  he  had  lost  forty  five  pounds  in  weight.  Kxamination  at 
this  time  revealed  the  existence  of  a  hard,  nodulated,  fixed  swelling  in  the  ileocecal 
region,  and  tym[>anites  in  the  hypogastric  and  umbilical  ngions.  Distention  of  the 
colon  by  rectal  insufllation  of  hydrogen  gas  made  the  swelling  mf>re  prominent  and  de- 
fined. There  was  not  much  tenderness  on  pressure.  Digital  exi)loralion  of  the  rectum 
yielded  a  negative  result.  Marasmus  and  anemia  were  well  marked.  I'or  the  Inst 
seven  months  the  jKitient  had  from  four  to  six  lirpiirl  discharges  daily  from  the  bowels. 
Apfx-lile  was  impaired.  There  was  slight  rise  in  tin-  evening  temperature,  anfi  the 
pulse-rate  was  from  eighty  to  ninety  a  minute.      From   the  history  of  the  case,  and  more 


952  TUBERCULOSIS. 

especially  from  the  character  and  location  of  the  swelling,  a  probable  diagnosis  of  tuber- 
culosis of  the  cecum  was  made.  As  the  usual  medical  treatment,  which  had  been  pur- 
sued for  months,  afforded  but  temporary  relief,  the  consent  of  the  patient  and  his  friends 
to  an  operation  was  readily  obtained.  Laparotomy  was  performed  on  the  day  of  his 
admission  into  the  hospital.  The  abdomen  was  opened  by  an  incision  from  near  the 
middle  of  Poupart's  ligament  to  a  point  half-way  between  the  anterior  superior  spinous 
process  of  the  ilium  and  umbilicus.  On  opening  the  abdomen  the  swelHng  at  once  came 
within  easy  reach.  Examination  showed  that  the  swelling  involved  the  entire  circumfer- 
ence of  the  cecum,  and  its  immobility  suggested  that  it  was  intimately  connected  with 
the  retroperitoneal  tissues  by  inflammatory  adhesions.  The  lower  portions  of  the  ileum 
and  cecum  were  emptied  by  displacing  their  contents,  and  each  part  was  intmsted  to  an 
assistant,  who  was  instructed  to  prevent  fecal  extravasation  by  digital  compression  until 
the  completion  of  the  anastomosis.  The  ascending  colon  was  divided  about  two  inches 
below  the  margin  of  the  swelling  and  the  ileum  near  its  junction  with  the  cecum  ;  both 
sections  showed  that  the  visceral  incisions  had  been  made  through  healthy  tissue.  The 
bleeding  vessels  were  tied  with  fine  silk  ligatures.  Several  large,  partially  caseous 
glands  were  found  in  the  retroperitoneal  space  behind  the  cecum,  and  enucleated  in  one 
large  mass  with  the  cecum  and  a  portion  of  peritoneum  which  was  adherent  to  the 
glands.  After  the  removal  of  the  cecum  it  was  noticed  that  the  mesentery  of  the  lower 
portion  of  the  ileum  contained  several  enlarged  glands  ;  consequently,  after  preliminary 
ligation,  it  was  excised  with  eighteen  inches  of  the  ileum.  During  the  whole  operation 
a  small  compress  was  kept  in  the  abdominal  cavity  to  prevent  prolapse  of  the  small  intes- 
tine and  to  guard  against  infection.  After  all  hemorrhage  had  been  carefully  arrested, 
both  ends  of  the  bowel  were  closed  by  invagination  and  a  few  stitches  of  the  continuous 
suture  ;  the  first  stitch  was  made  to  transfix  the  mesentery  at  the  point  where  it  was 
invaginated  into  the  bowel.  Medium-sized  perforated  decalcified  bone-plates  were  used 
in  making  the  ileocolostomy  by  lateral  approximations.  An  incision  about  two  inches  in 
length  near  the  closed  ends  of  both  intestines  was  made  at  a  point  opposite  the  mesen- 
teric attachment,  and  into  each  opening  a  bone-plate  was  inserted  ;  the  lateral  sutures, 
armed  with  a  needle,  were  passed  about  an  eighth  of  an  inch  from  the  margin  of  the 
visceral  wound,  from  within  outward,  at  a  point  half-way  between  the  angles  of  the 
wound,  and  in  such  a  way  as  not  to  include  the  peritoneum.  The  surfaces  of  the  bowel 
corresponding  to  the  part  covering  the  plates  were  freely  scarified  with  an  ordinary  sew- 
ing needle.  The  visceral  wounds  were  now  brought  vis-d-vis  in  such  a  manner  that  both 
closed  ends  were  directed  downward,  in  this  way  bringing  together  the  free  surfaces  of 
the  colon  and  ileum.  Before  any  of  the  plate  sutures  were  tied  a  number  of  Lembert 
sutures  were  applied  posteriorly,  so  as  to  approximate  the  serous  surfaces  along  the 
margin  of  the  plates,  thus  affording  additional  security  in  maintaining  coaptation.  The 
posterior  pair  of  approximation  sutures  were  now  tied  with  sufficient  firmness  to  hold  the 
parts  in  contact  without  sufficient  pressure  to  cause  gangrene,  after  which  both  pairs  of 
sutures  not  armed  with  needles  were  tied.  During  the  tying  of  these  sutures  it  is  of  the 
greatest  importance  that  an  assistant  keep  the  plates  accurately  and  closely  pressed 
together.  The  last  to  tie  was  the  second  anterior  pair  of  transfixion  sutures,  and  as  this 
was  being  done  the  bowel  on  each  side  was  carefully  pushed  in  between  the  plates  with 
a  probe.  After  all  the  approximation  sutures  were  tied,  it  remained  only  to  apply  a  few 
Lembert  sutures  on  the  anterior  side.  After  the  exposed  parts  were  disinfected  and 
dried,  the  bowel  was  returned  into  the  abdominal  cavity  and  anchored  near  the  wound 
with  a  silk  suture,  at  a  point  opposite  the  anastomotic  opening  ;  the  suture  was  made  to 
embrace  the  parietal  peritoneum  on  one  side  and  the  mesentery  on  the  other.  The 
abdominal  incision  was  sutured  throughout  ;  no  provision  was  made  for  drainage.  The 
subsequent  history  of  the  case  was  uneventful.  The  highest  temperature  registered  was 
on  the  third  day,  when  it  reached  101.5°  F-,  but  returned  to  normal  on  the  fourth  day. 
During  the  first  two  days  liquid  food  was  administered  by  rectum.  After  that  time  the 
patient  was  allowed  milk,  beef-tea,  and  raw  eggs,  and  after  another  week  he  was  given 
the  ordinary  hospital  diet,  which  he  relished.  The  bowels  moved  several  times  a  day, 
the  passages  gradually  becom.ing  normal  in  color  and  consistence.  The  external 
wound  healed  by  primary  intention  with  the  exception  of  a  small  place  where  a  stitch 
abscess  fomied  at  the  end  of  the  first  week.  At  the  ninth  day  half  of  the  plate  in  the 
colon  passed  per  rectum,  and  the  following  day  the  remaining  half,  together  with  the 
plate  from  the  ileum  with  the  sutures  attached,  was  found  in  one  of  the  stools.  The 
patient  left  his  bed  on  the  twenty-eighth  day  after  the  operation,  and  three  days  later  he 
returned  tohis  home.  At  the  time  he  left  the  hospital  nothing  abnormal  could  be  felt  in 
the  right  iliac  fossa,  and  there  were  no  pain  and  no  tenderness  on  pressure.  He  gained 
rapidly  in  flesh  and  strength,  and  when  I  saw  him  again,  during  the  latter  part  of  Janu- 
ary, 1890,  he  weighed  nearly  as  much  as  before  he  was  taken  ill.  Since  the  operation 
he  has  had  no  pain,  no  diarrhea,  and  the  discharges  from  the  bowels  once  or  twice  a  day 


ENTERO-AXASTOMOSIS.  gr 


found.      In  the  course  of  a  few  months  the  patient  died  from  the  effects  of    he  .ecu  rent 
disease  without  any  symptoms  of  obstruction.  lecuirent 

It  is  a  source  of  regret  that  a  second  radical  operation  was  not 
performed,  as  repeated  operations  have  finally  yielded  radical  results 
Ihe  specimen  removed  represents  the  entire  cecum,  a  number  of 
chees)'  mesenteric  and  retroperitoneal  glands,  eighteen  inches  of  the 
ileum,  with  the  corresponding  mesentery.  A  few  small  tubercular 
ulcers  were  found  in  the  lower  portion  of  the  section  of  the  ileum 
removed.  The  tubercular  process  had  evidenth'  started  in  the 
cecum,  which  it  involved  in  its  entire  circumference.  The  walls  of 
the  cecum  had  become  greatly  thickened  by  the  infiltrations.  The 
lumen  of  the  ileocecal  valve  w^as  not  larger  than  an  ordinary  lead- 
pencil,  and  the  interior  of  the  cecum,  near  the  valve,  presented  a 
number  of  deep  excavations  resulting  from  the  breaking  down  and 
ulceration  of  the  tubercular  mass.  The  ileum  for  a  considerable 
distance  was  the  seat  of  a  well-marked  compensatory  hypertrophy, 
the  thickening  of  its  walls  being  due  to  an  increase  in  muscular 
fibers,  a  result  that  so  constantly  follows  progressive  intestinal  steno- 
sis. The  presence  of  numerous  caseous  mesenteric  and  retroperito- 
neal lymphatic  glands,  the  character  of  the  ulcers,  and  microscopic 
examination  of  the  diseased  tissues  removed  proved  the  tubercular 
nature  of  the  inflammatory  process. 

From  the  accumulated  experience  of  the  past  in  the  treatment 
of  intestinal  tuberculosis  by  resection  it  becomes  c\-ident  that  this 
operation  is  indicated  in  all  cases  in  which  the  disease  is  sufficiently 
circumscribed  to  admit  of  complete  removal,  and  the  general  condi- 
tion of  the  patient  is  such  as  to  entitle  us  to  the  hope  that  the  opera- 
tion will  not  prove  fatal  by  its  immediate  effects.  It  is  in  such  well- 
selected  cases  that  enterectomy  will  yield  far  better  results  than  any 
other  operative  procedure,  as  it  has  for  its  object  the  complete 
eradication  of  the  disease,  thus  protecting  the  patient  against  rein- 
fection from  this  source. 

Partial  Physiologic  Exclusion  of  Affected  Portion  of  Intestinal 
Canal  by  Entero-anastomosis . — Ten  years  ago  I  made  a  series  of 
experiments  on  the  lower  animals  for  the  purpose  of  demonstrating 
the  value  of  partial  physiologic  exclusion  of  the  intestine  by  entero- 
ana.stomosis  in  the  treatment  of  certain  localized  affections  not  amena- 
ble to  resection.  The  results  of  the  experiments  j)r()ved  that  tiie 
excluded  portion  undergoes  atrophy  and  is  placed  in  a  condition 
approaching  physiologic  re.st.  In  none  of  the  ex|x-riments  did  the 
excluded  portion  become  the  seat  of  fecal  accumulation. 

In  the  introduction  to  this  section  the  statement  was  made  :  "As 
extensive  resections  of  the  intestine  are  alwaj-s  attended  by  great 
risks  to  life  from  trauma,  it  was  decided  to  stnd\'  tiie  subject  of 
sudden  deprivation  f;f  the  .system  of  a  more  or  less  extensive  .surface 


954 


TUBERCULOSIS. 


for  digestion  and  absorption,  by  eliminating  or  diminishing  the  cause 
of  death  from  this  source,  by  leaving  the  intestine,  but  by  exclud- 
ing permanently  a  certain  portion  from  participating  in  the  functions 
of  digestion  and  absorption  ;  in  other  words,  by  resorting  to  physi- 
ologic exclusion.  These  experiments  were  also  made  to  determine 
the  tissue  changes  that  would  take  place  in  the  bowel  thus  excluded, 
and  to  learn  if,  under  such  circumstances,  accumulation  of  intestinal 
contents  would  take  place  and  constitute  a  source  of  danger,  as  had 
been  feared  by  the  older  surgeons." 

The  results  of  the  experiments,  as  well  as  clinical  experience 
since  that  time,  have  shown  conclusively  that  this  fear  is  unfounded. 
In  speaking  of  the  results  of  the  experimental  work  and  its  applica- 
tion in  intestinal  surgery,  the  following  statements  were  made  in 
connection  with  the  same  subject :  "■  The  exclusion  was  complete, 
or  nearly  so  ;  hence  we  must  conclude  from  the  postmortem  appear- 
ances that  in  nearly  every  instance  the  excluded  portion  presented  an 
atrophic,  contracted  condition,  and  was  only  sparingly  suppHed  with 
blood-vessels.  From  a  practical  standpoint  these  experiments  teach 
us  that  a  limited  portion  of  the  intestinal  canal  can  be  permanently 
excluded  from  the  processes  of  digestion  and  absorption  in  proper 
cases,  by  operative  measures,  without  incurring  any  risk  of  fecal 
accumulation  in  the  excluded  part.  These  experiments  demonstrate 
also  that  physiologic  exclusion  of  a  certain  portion  of  the  intestinal 
tract  is  a  less  dangerous  operation  than  excision,  and  that  in  certain 
cases  of  intestinal  obstruction  where  excision  has  heretofore  been 
practised  it  can  be  resorted  to  as  a  substitute  for  this  operation  in 
cases  where  excision  is  impracticable  or  where  the  pathologic  con- 
ditions that  have  caused  the  obstruction  do  not,  in  themselves,  con- 
stitute an  intrinsic  source  of  immediate  or  remote  danger  to  life. 
The  postmortem  appearances  of  the  specimens  of  these  experiments 
tend  to  prove  that  as  long  as  any  of  the  contents  of  the  intestines 
reach  the  excluded  portion,  the  peristaltic  or  antiperistaltic  action  in 
that  part  is  effective  in  forcing  it  back  into  the  active  current  of  the 
fecal  circulation." 

Since  that  time  entero-anastomosis  has  become  a  well-established 
operation,  and  has  proved  of  signal  success  in  the  treatment  of  lim- 
ited intestinal  tuberculosis,  complicated,  as  it  so  often  is,  by  cicatri- 
cial stenosis.  The  operation  effects  two  desirable  objects  in  the 
treatment  of  such  cases  :  (i)  It  relieves  the  symptoms  of  intestinal 
obstruction  ;  (2)  it  secures  rest  for  the  part  affected.  I  have  had 
an  opportunity  of  performing  entero-anastomosis  in  two  cases  of 
intestinal  tuberculosis. 

Intestinal  Tuberculosis  Complicated  by  Acute  Intestinal  Obstruction  Caused  by  Cica- 
tricial Stenosis. — Ileo-ileostomy  ;  recovery  ;  patient  in  almost  perfect  health  two  years 
after  the  operation.  The  patient  was  a  boy  sixteen  years  of  age,  a  member  of  a  healthy 
family,  free  from  any  predisposition  to  tuberculosis  or  malignant  disease.  He  had  never 
been  seriously  ill  and  was  in  the  best  of  health, — weight,  140  pounds, — when  he  was 
attacked  with  colicky  pain,  which  he  referred  to  the  umbilical  region,  December,  1895, 
the  pain  continuing  for  two  days.      He  recovered  from  this  attack  and  remained  in  fair 


ENTERO-AXASTOMOSIS. 


955 


health  until  December  i8,  1896,  when  he  was  again  seized  with  severe  pains  of  a  colicky 
nature  in  the  abdomen,  which  continued  until  he  entered  the  hospital.  Bowels  had  not 
moved  for  two  days  prior  to  his  present  illness.  Vomiting,  which  soon  became  fecal  and 
absolute  constipation  followed  by  great  tympanites  came  on  in  rapid  succession.  The 
attending  physician  made  a  diagnosis  of  intestinal  obstruction  and  resorted  to  the  u.sual 
treatment,  including  the  use  of  high  rectal  eneniata,  with  little  or  no  relief.  When  he  was 
admitted  into  St.  Joseph's  Hospital,  March  i,  1896,  he  had  lost  forty  pounds.  He  was 
very  anemic,  and  the  emaciation  was  pronounced.  The  abdomen  was  enormously  dis- 
tended, and  visible  intestinal  coils  could  be  distinctly  outlined.  Temperature  was  normal, 
pulse  small  and  100  a  minute.  There  had  been  no  free  movements  from  the  bowels  smce 
the  attack.  There  were  frequent  attacks  of  vomiting,  at  times  fecal  in  character.  Rectal 
examination  yielded  no  infomiation  regarding  the  anatomic  location  or  nature  of  the  obstruc- 
tion. The  day  after  his  admission  into  the  hospital,  after  thorough  preparatory  treatment, 
laparotomy  was  performed.  The  abdomen  was  opened  in  the  median  line,  half-way 
between  the  umbilicus  and  pubes.  Intestinal  coils  were  enormously  distended  and  exceed- 
ingly vascular,  protruded  at  once  from  the  wound,  and  were  carel'ully  protected  with  com- 
presses wrung  out  of  a  hot  physiologic  solution  of  salt.  One  of  the  first  things  noticed 
was  the  existence  of  numerous  enlarged  mesenteric  glands.  Some  of  them  were  the  size 
of  a  hazelnut  and  presented  distinct  evidences  of  beginning  caseation.  The  visceral  as 
well  as  the  parietal  peritoneum  was  studded  with  innumerable  tubercle  nodules.  The 
existence  of  peritoneal  and  glandular  tuberculosis  was  at  once  made  evident.  In  search- 
ing for  the  seat  of  the  obstruction  the  distended  intestine  was  traced  in  a  downward  direc- 
tion, the  intestinal  loops  being  replaced  as  soon  as  examined  so  as  to  prevent  extensive 
eventration.  In  reaching  the  lower  part  of  the  ileum,  the  obstruction  was  found  about 
twelve  inches  above  the  ileocecal  junction,  in  the  form  of  a  tight  circular  stricture.  Above 
this  point  the  intestine  was  uniformly  distended  and  very  vascular,  while  below  the  obstruc- 
tion the  intestine  was  empty,  contracted,  and  pale.  An  ileo-ileostomy  was  made  by  estab- 
lishing an  anastomotic  opening  between  the  lower  part  of  the  distended  ileum  and  that 
part  of  the  ileum  between  the  obstruction  and  the  cecum.  Before  the  visceral  incisions 
were  made  the  serous  surfaces  of  the  convex  side  of  the  intestinal  loops  which  were  to  be 
united  were  sutured  together  with  a  row  of  Lembert  stitches,  extending  a  little  beyond 
the  intended  limits  of  the  incisions.  On  incising  the  proximal  distended  loop  the  bowel 
was  drawn  well  forward,  the  patient  placed  on  his  right  side,  and  as  much  of  the  iTites- 
tinal  contents  as  could  be  poured  out  was  evacuated  through  the  incision.  After  incising 
the  empty  loop  to  the  same  extent  the  mucous  membrane  was  sutured  all  around,  and 
finally  a  row  of  anterior  serous  stitches  completed  the  operation.  The  parts  ex])osed 
were  thoroughly  cleansed,  dried,  and  lightly  dusted  with  iodoform,  after  which  the  intes- 
tines were  returned  and  the  external  incision  closed  in  the  usual  manner.  The  patient 
recovered  promptly  from  the  immediate  effects  of  the  operation.  The  incision  healed 
throughout  by  primary  intention.  The  bowels  moved  freely  the  day  after  tlie  operation. 
The  tympanites  diminished  rapidly  and  disappeared  entirely  in  the  course  of  a  week. 
For  a  few  days  the  stools  were  copious  and  liquid  ;  later,  once  a  day  and  normal  in  color 
and  consistence.  Rectal  feeding  was  continued  ft^r  four  days  ;  later,  liquid  food  was  given 
by  the  stomach,  followed  by  solid  food  at  the  end  of  the  first  week.  The  patient  left  the 
hospital  in  excellent  condition  March  30,  i8g6.  A  letter  from  his  physician  received  two 
years  after  the  operation  states  that  he  is  in  perfect  health,  having  gained  twenty-seven 
pounds  in  weight. 

Careful  search  for  tuberculosis  in  other  organs  was  made,  with 
negative  result.  The  tubercular  nature  of  the  intestinal  affection 
in  this  case  was  obvious  from  the  .simultaneous  existence  of  ])cri- 
toneal  and  lymphatic  tuberculosis.  The  cntero-anastomosis  relieved 
the  obstruction  promptly  and  placed  the  affected  organs  in  a  con- 
dition for  spontaneous  healing  of  the  tubercular  lesion.s.  The 
patient  was  placed  upon  the  prolonged  internal  use  of  guaiacol, 
which  may  have  contributed  to  the  remarkal)le  result  of  the  opera- 
tion. 

Tubi-rcttlosis  of  the  Cecum  and  Aacendittf^  Colon,  Coiiipliculi-ii  hy  7'ii/>rnii/osi^  0/  ihf 
Urinary  Organs. — Ileosigmoidrtslomy  ;  dtalh  from  cxhaiislion  forty-i-ighl  liours  nflcr 
operation.  The  patient  was  a  man  lliirty-eighl  years  of  age,  who  was  achnilled  into  ihc 
Presbyterian  Mf)spital  .N'ovemiicr  6,  1897.  His  healdi  ixgan  to  declinf  four  years  ago, 
when  symptoms  of  chronic  cy.stitis  developed.      For  a  l-ta;  time  the  urine  contained  pus 


956  TUBERCULOSIS. 

and  at  times  blood.  In  February,  1896,  he  had  a  chill,  followed  by  fever  and  pain  in 
the  region  of  the  right  kidney.  A  swelling  developed  below  the  costal  arch  on  the 
same  side  and  soon  reached  as  far  as  the  crest  of  the  ilium,  and  to  within  an  inch  or  two 
of  the  median  line  on  the  left.  The  temperature  ranged  between  102°  and  104°  F.  for 
five  days.  A  second  chill  occurred  a  few  days  later,  followed  by  slight  jaundice,  which 
continued  for  a  few  days.  The  swelling  was  diagnosticated  as  an  abscess,  which  was 
incised  in  front  at  a  point  half-way  between  the  last  rib  and  the  crest  of  the  ilium.  On 
cutting  through  the  abdominal  wall  the  distended  kidney  presented  itself  and  was  in- 
cised, about  a  pint  of  pus  escaping.  The  cavity  was  washed  out  and  drained.  For 
some  time  urine  escaped  through  the  drainage  opening.  Three  weeks  after  the  operation 
feces  escaped  through  the  opening,  and  the  fecal  fistula  has  remained  since  that  time. 
At  the  time  the  patient  entered  the  hospital  he  was  very  anemic  and  greatly  emaciated. 
Examination  of  the  bladder  and  prostate  left  no  doubt  that  both  of  these  organs  were 
the  seat  of  a  tubercular  affection.  Through  the  fistulous  opening  a  probe  could  be  in- 
serted into  the  ascending  colon.  Gas  and  fecal  material  escaped  through  the  opening 
daily.  Action  of  bowels  irregular,  diarrhea  and  constipation  alternating.  From  the 
cecum,  in  the  course  of  the  colon,  a  resistant  swelling  could  be  felt  that  extended  some- 
what above  the  fistulous  opening.  Examination  of  the  lungs  revealed  a  limited  infiltra- 
tion in  the  left  apex.  A  slight  rise  in  the  evening  temperature  was  an  almost  constant 
feature.  The  fistulous  opening  externally  was  enlarged,  and  a  large  cavity  found  be- 
tween the  skin  and  abdominal  muscles,  which  was  lined  with  fungous  granulations. 
These  were  scraped  out  with  a  sharp  spoon,  and  the  cavity  was  thoroughly  disinfected 
and  packed  with  iodoform  gauze.  This  and  the  subsequent  operations  were  perfo;:med 
in  the  clinic  of  Rush  Medical  College.  The  scraping-out  of  the  cavity  was  followed  by 
increased  fecal  discharge,  and  in  a  short  time  the  fistulous  opening  ni  the  colon  was  large 
enough  to  insert  the  tips  of  two  fingers.  Carbonate  of  guaiacol  and  tonics  were  admin- 
istered internally,  but  the  patient  continued  to  lose  strength  and  flesh.  Owing  to  the 
existence  of  formidable  complications  and  the  extent  of  the  intestinal  affection  it  was 
decided  to  exclude  the  cecum  and  colon,  as  far  as  the  sigmoid  flexure,  from  the  fecal  cir- 
culation, by  performing  ileosigmoidostomy. 

After  careful  preparations  the  operation  was  performed  December  20,  1897.  The 
abdomen  was  opened  in  the  median  line.  The  cecum  and  ascending  colon,  nearly  as 
far  as  the  hepatic  flexure,  were  found  embedded  in  an  extensive  exudate.  Numerous 
enlarged  lymphatic  glands,  especially  in  the  mesocecum  and  mesentery  of  the  ascending 
colon.  The  anastomotic  opening  was  established  between  the  ileum,  about  eighteen 
inches  above  the  cecum,  and  the  sigmoid  flexure.  The  operation  was  performed  in  the 
same  manner  as  in  the  case  of  lateral  anastomosis  after  excision,  with  the  exception 
that  no  bone-plates  were  used,  the  visceral  wounds  being  united  by  two  rows  of  sutures. 
The  operation  was  completed  in  less  than  an  hour.  Very  little  shock  followed.  The 
next  day,  however,  vomiting  and  symptoms  of  prostration  set  in,  the  pulse  became  more 
rapid  and  feeble,  but  the  temperature  never  exceeded  Ioo°  F.  Death  occurred  forty- 
nine  hours  after  the  operation. 

The  clinical  history  in  this  case  points  to  primary  tubercu- 
losis of  the  urinary  organs,  followed  by  intestinal  and,  later,  pul- 
monary tuberculosis.  A  number  of  cases  have  been  reported  in 
which  entero-anastomosis  was  performed  for  intestinal  tuberculosis. 
Hofmeister  reports  a  case  of  multiple  tubercular  strictures  of  the 
intestine  treated  by  establishing  an  entero-anastomosis.  The  pa- 
tient, a  man  aged  thirty-two,  had  suffered  for  four  years  with 
attacks  of  coHc  accompanied  by  vomiting  and  constipation,  recur- 
ring at  intervals  of  greater  or  less  length,  the  last  seizures  having 
been  particularly  severe.  Finally  the  patient  was  taken  to  the  sur- 
gical clinic  of  Bruns,  at  Tiibingen,  Avith  all  the  symptoms  of  a 
marked  intestinal  obstruction.  The  operation,  which  was  under- 
taken Avithout  delay,  revealed  ten  annular  strictures  of  the  small 
intestine,  for  the  most  part  very  narrow  and  distributed  over  two 
meters  of  the  bowel.  The  large  intestine  was  entirely  empty  and 
contracted.  Resection  being  out  of  the  question  on  account  of 
the  debilitated  general  condition  of  the  patient,  an  anastomosis  was 


ENTERO-ANASTOMOSIS. 


957 


made  between  the  intestines  above  and  below  the  seat  of  obstruc- 
tion. At  the  very  outset  the  distended  intestine  was  punctured 
with  a  small  trocar,  to  evacuate  its  contents.  The  puncture  was 
closed  with  two  rows  of  sutures.  The  patient  improved  tempora- 
rily as  a  result  of  the  operation,  but  died  the  following  day  in  sud- 
den collapse.  The  autopsy  revealed  the  fact  that  death  had  been 
caused  by  a  general  peritonitis.  Inspection  showed  that  the  sutures 
inserted  for  the  purpose  of  closing  the  puncture  opening  were  in- 
sufficient to  resist  the  intra-intestinal  pressure  by  gas,  and  had 
given  way,  followed  by  fecal  extravasation.  Besides  the  ten  dis- 
covered at  the  operation,  two  additional  strictures  were  found,  one 
near  the  ileocecal  valve  and  the  other  a  little  higher  up.  When 
the  strictures  are  multiple,  the  disease  usually  involves  the  ileum. 
Hofmeister  found  records  of  eighteen  cases  of  multiple  strictures 
of  the  intestines  of  a  tubercular  nature. 

Marwedel  reports  a  case  of  tuberculosis  of  the  cecum  from 
Czerny's  clinic  treated  by  entero-anastomosis : 

The  patient  was  a  man  forty-three  years  of  age.  No  hereditary  predisposition  to 
tuberculosis  in  the  family.  He  suffered  from  two  attacks  of  localized  peritonitis,  probably 
caused  by  appendicitis,  the  first  in  1870,  the  second  in  1887.  Since  last  attack  pain  and 
tenderness  in  the  right  iliac  fossa  remained.  In  1 891  the  pain  increased,  attended  by 
colicky  pains  in  the  abdomen,  the  latter  disappearing  after  two  or  three  minutes  with  a 
loud  pouring  sound.  Bowel  movements  were  irregular.  A  few  weeks  before  his  admit- 
tance into  the  clinic  eructations  and  transient  vomiting  returned.  He  was  treated  for 
some  time  in  the  medical  clinic  by  high  enemata,  without  any  benefit.  He  was  admitted 
into  the  surgical  clinic  August  17,  1893.  At  this  lime,  with  the  exception  of  a  chronic 
conjunctivitis,  rhinitis,  pharyngitis,  and  a  slight  pulmon.iry  emphysema,  the  general  health 
of  the  patient  did  not  appear  to  be  much  impaired.  Cecal  region  was  prominent,  and  to 
the  right  of  the  cecum  and  ascending  colon,  particularly  the  latter,  a  hard,  cylindric  swell- 
ing could  be  felt,  e.xtending  from  the  iliac  spine  to  the  tip  of  the  eleventh  rib.  The  swell- 
ing was  fixed  and  tender  on  pressure,  and  there  was  visible  peristalsis  of  the  small  intes- 
tine near  the  cecum. 

Clinical  Diai^nosis. — Stenosis  and  tumor  formation  in  the  region  of  the  cecum  and 
ascending  colon  ;  chronic  inflammatory,  perhaps  tubercular,  process.  First  operation, 
August  20,  1893.  Vertical  incision  in  the  linea  S|)igelii  showed  infiltration  of  |)repcri- 
toneal  tissues  and  firm  adiiesions  between  anterior  abdominal  wall  and  ascending  colon. 
In  separating  the  adhesions  an  ulcerated  portion  of  the  colon  near  its  middle  was  torn, 
and  a  quantity  of  pus,  but  no  fecal  material,  escaped.  From  this  opening  digital  explora- 
tion showed  that  the  colon  was  ulcerated  as  far  as  the  ileocecal  valve,  which  induced  the 
operator  to  abandon  all  thoughts  of  performing  a  resection.  The  tear  in  the  bowel  was 
sutured  and  an  entero-anastomosis  made.  The  lower  jiortion  of  the  ileum  was  <lislended 
and  hypertrophied  ;  on  the  other  hand,  the  transverse  colon  was  contracted  and  alropliied. 
These  two  parts  of  the  intestinal  canal  were  then  brought  into  connnuiiication,  and,  by 
incision  and  suturing,  a  free  anastomotic  opening  was  established.  The  sutured  wound 
of  the  colon  was  fastened  to  the  abdominal  wall  with  two  peritoneal  sutures.  External 
incision  was  closed,  with  the  excejition  of  a  space  over  the  cecum  to  secure  drainage, 
which  was  effected  l)y  using  the  iodoform  gauze  tampon.  The  diagnosisninde  at  this 
time  confirmed  the  previous  suspicion  of  the  tubercular  nature  of  the  affection,  liowels 
moved  on  the  second  day,  after  the  use  of  an  enema.  A  week  after  the  o])<ratinn  some 
fecal  matter  was  mixed  with  the  discharge  from  the  wound.  When  the  patient  was  dis- 
charged, four  weeks  after  the  r)peration,  the  wr.und  was  healed,  with  the  exception  of  a 
fistula,  which  discharged  a  small  .juantily  of  i)us,  Init  no  fetal  material,  {{cnvels  moved 
without  the  aid  of  cathartics  or  enemata.  General  conditions  nmch  improved.  During 
the  fall  of  the  same  year  he  was  attacked  with  influenza,  and  af  the  termination  of  the 
illness  the  parts  around  the  fistula  became  inflamed,  and  S(«)n  after  a  nion-  copious  flow 
of  pus  ensued,  which  became  mixed  with  feces.  He  reentered  the  clinic  .November  30, 
1893.  The  swelling  in  the  cecal  r(gi<m  was  smaller,  but  firmi-r,  than  at  the  tune  of  oper- 
ation. There  was  constipation,  which,  when  relieved  by  cathartics,  was  followecl  by 
diarrhea,  some  of  the  fecal  material  escaping  through  tlie  fistula.      At  this  tune  the  fistu- 


958  TUBERCULOSIS. 

lous  tract  was  enlarged  with  the  knife  sufficiently  to  enable  exploration  of  the  abscess 
cavity  with  the  finger.  The  cavity  was  about  the  size  of  a  walnut,  partly  filled  with  hard 
fecal  masses,  and  lined  with  tubercular  granulations.  Curettage  and  iodoform  gauze 
tamponade  were  used.  After  operation  nearly  all  the  feces  escaped  through  the  fistula. 
A  third  operation  was  performed  December  7th  of  the  same  year.  The  old  scar  was  in- 
cised, and  the  adherent  ascending  colon  separated.  During  this  step  of  the  operation  a 
small  subcutaneous  abscess  was  opened  The  fistulous  opening  was  next  exposed  and 
was  located  near  the  lower  end  of  the  ascending  colon,  where  a  defect  was  found  large 
enough  to  admit  the  tip  of  the  index -finger.  Exploration  of  the  interior  of  the  cecum  re- 
vealed a  large  cicatrized  surface.  The  margins  of  the  intestinal  fistula  were  vivified,  and 
the  opening  was  closed  with  two  rows  of  sutures,  the  operation  being  entirely  extraperi- 
toneal. The  external  incision  was  closed,  with  the  exception  of  a  space  large  enough  to 
bring  out  the  iodoform  gauze  tampon.  No  unfavorable  symptoms  followed  the  operation. 
Normal  stool  followed  after  injection  on  the  eighth  day.  Patient  left  the  hospital  on  the 
last  day  of  the  same  month,  with  a  small  fistula,  but  almost  in  perfect  health,  and  with 
normal  bowel  movements.  One  year  later  the  fistula  still  remained,  and  at  times  small 
quantities  of  feces  escaped ;  otherwise  the  patient  was  in  good  health  and  had  gained 
twenty-three  pounds  in  weight.  Czerny  attributes  the  healing  of  the  extensive  tubercular 
ulcerations  to  the  elimination  of  the  affected  part  of  the  bowel  from  the  fecal  circulation 
by  the  ileocolostomy. 

Schiller  reports  three  cases  of  intestinal  tuberculosis  treated  by 
physiologic  exclusion  of  the  affected  part,  operated  upon  in  Czerny's 
clinic  during  a  period  of  four  years.  In  all  cases  the  disease  was 
located  in  the  cecum  and  had  given  rise  to  chronic  obstruction.  In 
two  cases  the  anastomotic  opening  was  made  between  the  ileum  and 
the  transverse  colon,  and  one  between  the  ileum  and  the  ascend- 
ing colon.  In  two  cases  the  cecum  was  incised  and  the  tuber- 
cular ulcers  were  curetted.  The  visceral  incision  was  closed  by 
suturing  parallel  with  the  long  axis  of  the  bowel.  In  one  case  the 
diseased  appendix  was  excised  in  addition.  In  one  the  gall-bladder 
was  extirpated  at  the  same  time  for  lithiasis  and  chronic  inflamma- 
tion. In  all  the  cases  the  contraindications  to  resection  were  well 
defined.  In  one  case  the  operation  was  done  by  the  use  of  the  Mur- 
phy button,  which  was  removed  from  the  ampulla  of  the  rectum  on 
the  fifteenth  day,  after  a  severe  hemorrhage  three  days  previously. 
The  pulmonary  symptoms  became  seriously  aggravated  after  the 
hemorrhage.  All  these  cases  recovered,  and  the  patients  left  the 
hospital  improved.  In  one  case  (reported  in  extenso  above)  a  fecal 
fistula  developed,  which  was  sutured  on  two  occasions  with  partial 
success. 

The  exclusion  of  the  affected  part  of  the  intestine,  although  not 
complete,  led  to  speedy  healing  of  the  ulceration,  as  was  shown  in 
one  case  at  the  second  operation,  four  and  one-half  months  later. 
The  healing  of  the  ulcers  was  undoubtedly  favored  by  the  atrophy 
and  diminished  peristaltic  action,  conditions  that  are  always  estab- 
lished in  the  excluded  part  soon  after  the  operation. 

James  Israel  reported  to  the  Surgical  Society  of  Berlin  a  case 
of  tuberculosis  of  the  cecum  and  ascending  colon  in  a  woman 
twenty  years  of  age,  which  was  greatly  improved  by  establishing  a 
communication  between  the  ileum  and  the  ascending  colon.  The 
disease  was  attended  by  symptoms  indicative  of  chronic  intestinal 
tuberculosis.  Exploratory  laparotomy  was  performed,  and  a  prob- 
able diagnosis  of  sarcoma  was  made.      The  mesenteric  glands  were 


ENTERO-ANASTOMOSIS. 


959 


found  enlarged.  Later  a  second  operation  was  performed,  when  a 
swelling  the  size  of  an  apple  was  found  projecting  into  the  ascendino- 
colon,  complicated  by  disseminated  peritoneal  tuberculosis.  The 
patient  made  a  good  recovery,  gained  in  weight,  and  after  seven 
months  the  swelling  was  reduced  in  size  to  that  of  a  walnut. 

Gessner  made  a  laparotomy  on  a  case  in  which  the  cecum  was 
tubercular  and  had  attained  the  size  of  a  goose  egg.  The  swelling 
was  nodulated,  and  the  serous  coat  studded  with  miliary  tubercles. 
The  obstruction  caused  by  cicatricial  stricture  in  the  region  of  the 
ileocecal  valve  was  relieved  by  an  anastomosis  between  the  ileum 
and  the  ascending  colon,  which  was  made  by  the  aid  of  the  Murphy 
button.  The  button  was  discharged  per  rectum  on  the  thirteenth 
day.      The  operation  was  followed  by  manifest  improvement. 

A  very  interesting  case  of  intestinal  tuberculosis  complicated 
by  invagination  came  under  the  obser\'ation  of  Czerny,  and  is 
reported  in  detail  by  Marwedel. 

The  patient  was  a  boy  fourteen  years  of  age,  who,  two  months  prior  to  his  admission 
into  Czerny' s  clinic,  was  suddenly  taken  ill  with  vomiting  and  severe  pain  in  the  abdo- 
men, attended  with  the  appearance  of  a  swelling  in  the  upper  and  right  side  of  the  abdo- 
men. In  a  few  days  the  pain  subsided  and  the  vomiting  occurred  less  frequently.  A 
sausage-shaped,  tender  swelling  above  the  umbilicus  remained.  Bowels  could  be  moved 
only  by  the  use  of  injections.  For  a  few  days  during  the  early  part  of  the  attack  the 
stools  contained  traces  of  blood.  On  his  admission  into  the  clinic,  June  2,  1894,  the 
patient  presented  an  anemic  appearance  and  was  considerably  emaciated.  There  was  no 
fever,  and  the  lungs  and  heart  were  normal.  Inspection  and  palpation  revealed  the 
existence  of  a  cylindric  swelling,  ten  centimeters  in  length,  in  the  region  of  the  trans- 
verse colon.  The  swelling  was  slightly  movable  and  tender  on  deej)  ])ressure.  The 
liver,  spleen,  and  kidneys  were  normal  in  size  and  function.  Under  rectal  insufflation 
the  swelling  increased  in  size,  and  dullness  on  percussion  gave  way  to  tympanitic  reson- 
ance. The  capacity  of  the  colon  was  only  three  pints.  The  rectal  injection  did  not  increase 
the  dullness  on  percussion  over  the  swelling,  and  was  followed  by  the  escaj^e  of  Iiard 
fecal  masses.  Chronic  invagination  of  ascending  and  transverse  colon  was  diagnosticated. 
Operation  was  performed  June  6th.  Median  incision  was  made  from  xiphoid  cartilage  to 
umbilicus,  and  later  had  to  be  extended  two  inches  to  bring  the  invaginated  colon  for- 
ward into  the  wound.  The  swelling,  the  size  of  two  fists,  was  composed  of  tlie  cecum 
and  ascending  colon,  into  which  the  lower  portion  of  the  ileum  had  become  invaginated. 
The  intussusception  could  be  traced  as  far  as  the  right  flexure  of  the  colon.  Reduclion, 
owing  to  the  presence  of  extensive  adhesions,  was  found  impossible,  and  resection  was 
contraindicated  by  the  debilitated  condition  of  the  j^atient.  An  entero-anastomosis 
between  the  ileum  above  the  invagination  and  the  middle  third  of  the  transverse  colon 
was  established  by  incising  the  previously  approximated  ileum  and  colon  and  suturing 
the  visceral  wounds  in  the  usual  manner  with  two  rosvs  of  sutures.  Abdominal  incision 
was  closed  throughout. 

The  existence  of  a  tubercular  lesion  of  the  invaginated  bowel  was  suspected  from 
the  presence  of  a  jjlastic,  caseous  perityphlitis.  Recovery  ensued  without  any  unt<iward 
symptoms.  Patient  left  the  hospital  August  9th,  the  swelling  being  much  diminished  in 
size  and  the  bowel  movements  normal.  A  year  later  the  patient  remained  in  giKxl 
health,  and  examination  showed  that  the  invagination  swelling  had  nearly  disappe.ired. 

The  tubercular  complication  presented  it.self  in  the  form  of 
ca.scous  adhesions  found  at  the  time  the  operation  was  performed. 
The  infection  probably  occurred  from  the  intesUnal  canal.  Whether 
the  tuberculosis  occurred  as  a  primary  affection  or  wiietlier  it  ap- 
I>eared  after  the  invagination  had  taken  place  would  he  dilficuU  to 
determine.  F"leiner  describes  two  other  cases  of  intestinal  tuber- 
culosis from  Czerny's  clinic,  in  which  the  pathologic  contiitions 
produced  by  the  disease  gave  rise  to  invagination. 


g6o  TUBERCULOSIS. 

The  cases  reported  furnish  conclusive  proof  of  the  thera- 
peutic value  of  entero-anastomosis  in  the  treatment  of  intestinal 
tuberculosis  sufficiently  limited  to  warrant  surgical  interference  and 
beyond  the  reach  of  successful  treatment  by  more  radical  measures. 

Complete  Pliysiologic  Exclusion. — Practical  experience  has  dem- 
onstrated the  value  of  partial  physiologic  exclusion  in  the  treat- 
ment of  certain  forms  of  localized  intestinal  tuberculosis.  It  would 
be  natural  to  assume  that  the  therapeutic  value  of  entero-anasto- 
mosis would  be  enhanced  if  the  affected  part  of  the  bowel  could  be 
completely  excluded  from  the  fecal  circulation,  thus  securing  for 
the  diseased  tissue  a  condition  of  absolute  rest.  At  the  time  I 
made  my  experiments  on  physiologic  exclusion  of  parts  of  the  in- 
testinal canal  I  had  this  object  in  view,  and  made  a  number  of 
experiments  to  demonstrate  the  possibility  and  practicability  of  the 
procedure.  The  exclusion  was  made  by  isolating  a  section  of  the 
intestine  and  closing  its  ends  by  invagination  and  a  few  Lembert 
sutures.  The  continuity  of  the  intestinal  canal  was  restored  by  cir- 
cular suturing  or  lateral  anastomosis.  The  results  of  these  experi- 
ments proved  unsatisfactory,  as  it  was  found  that  the  retained  in- 
testinal secretions  constituted  a  source  of  danger.  A  few  years 
later  Salzer  modified  the  operation  by  establishing  a  fistula  in  con- 
nection with  the  excluded  portion.  This  method  of  effecting 
complete  physiologic  exclusion  has  been  resorted  to  in  only  a  veiy 
few  instances  in  the  surgical  treatment  of  intestinal  tuberculosis. 

Of  the  cases  operated  upon  by  this  method,  the  one  reported  by  von  Eiselsberg  is 
the  most  instructive.  In  a  case  of  tuberculosis  of  the  cecum,  ascending  colon,  and 
hepatic  flexure,  this  surgeon  resorted  to  complete  physiologic  exclusion,  with  temporary 
benefit.  The  patient  was  a  man  thirty-five  years  of  age,  who  was  in  good  health  until  five 
years  before,  when  a  tubercular  affection  of  the  foot  developed,  followed  soon  by  symptoms 
of  acute  pulmonary  tuberculosis.  Two  years  later  the  head  of  the  tibia  was  operated 
upon  by  curettage  for  tubercular  caries.  During  the  healing  of  the  wound  the  patient 
suffered  from  an  attack  of  perityphlitis,  from  which  he  recovered,  but  the  disease  was 
followed  by  periodic  pains,  at  short  intervals,  in  the  ileocecal  region.  During  the  last 
few  months  the  pulmonary  symptoms  became  aggravated  and  an  obstinate  diarrhea  set 
in.  On  admission  into  the  hospital  examination  revealed  extensive  tubercular  infiltra- 
tion of  left  apex  of  the  lung  and  a  cylindric  swelling  in  the  region  of  the  cecum  ;  the 
swelling  was  somewhat  movable  and  tender  on  pressure.  Operation  was  commenced 
by  making  an  oblique  incision  directly  over  the  cecum.  The  cecum  was  found  smaller 
than  normal  and  not  adherent.  The  infiltration  extended  from  the  ileocecal  valve  to  the 
middle  of  the  transverse  colon.  The  affected  portion  of  the  bowel  was  completely 
excluded,  and  the  continuity  of  the  intestinal  canal  restored  by  circular  suturing  ;  the 
resected  end  of  the  ileum  had  to  be  joined  with  the  transverse  colon.  The  mucous  mem- 
brane at  the  points  of  section  appeared  to  be  healthy.  The  ends  of  the  excluded  por- 
tion were  fixed  in  the  upper  and  lower  angles  of  the  wound,  respectively,  and  the  bal- 
ance of  the  abdominal  incision  was  closed  in  the  usual  manner.  From  the  excluded 
portion  of  the  intestine  mucus  and  pus  escaped  in  considerable  quantities.  The  patient 
improved  temporarily.  On  the  seventh  day  the  affected  part  of  the  bowel  was  washed 
out  carefully  from  both  ends  with  a  warm  physiologic  solution  of  salt.  These  irriga- 
tions proved  the  competency  of  the  ileocecal  valve.  The  flushings  were  found  useful 
in  diminishing  the  amount  of  the  inflammatory  product.  The  patient  left  his  bed  in 
three  weeks.  A  few  days  later  the  pulmonary  symptoms  became  more  marked,  and 
when  the  patient  left  the  hospital,  a  week  later,  he  was  attacked  with  pulmonary  hemor- 
rhage, which  recurred  several  times  and  from  the  effects  of  which  he  died  two  months 
after  the  operation.  Diarrhea  reappeared  soon  after  the  operation,  and  continued  to  the 
end.  The  persistence  with  which  the  diarrhea  continued  soon  after  the  operation  tends 
to  establish  the  existence  of  the  tubercular  lesion  of  the  mucous  membrane  beyond  the 
limits  of  the  operation. 


BENIGN    TUMORS.  96 1 

Complete  physiologic  exclusion  will,  in  all  probability,  have  a 
very  limited  scope  in  the  surgical  treatment  of  intestinal  tubercu- 
losis, as  the  immediate  dangers  to  life  are  almost  equi\alent  to  the 
risks  incident  to  resection,  and  the  advantages  over  those  of  partial 
exclusion  are  not  sufficient  to  warrant  a  more  general  recourse  to 
this  procedure.  There  can  be  but  very  little  doubt  that,  with  an 
increased  knowledge  of  the  etiology  and  pathology  of  intestinal 
tuberculosis,  surgeons  will  be  induced  to  resort  to  operative  treat- 
ment more  frequently  in  the  future,  and  that  with  further  improve- 
ments in  the  technic  of  intestinal  operations  the  surgical  treatment 
will  yield  more  encouraging  results. 

TUMORS. 

A  tumor  may  give  rise  to  intestinal  obstruction  in  different  ways, 
according  to  its  location  and  anatomicopathologic  character.  A 
tumor  or  swelling  outside  of  the  intestinal  tube  may  cause  obstruc- 
tion by  compression.  A  polypoid  growth  springing  from  the  mucous 
or  submucous  tissue  interrupts  the  fecal  current  either  by  blocking 
the  lumen  of  the  bowel  by  its  size  or  by  causing  an  invagination  or 
flexion.  A  circular  carcinoma  produces  a  stenosis  that  leads  to 
chronic  obstruction,  but  that  is  frequently  the  indirect  cause  of  acute 
intestinal  obstruction,  when,  either  by  additional  pathologic  changes  at 
the  seat  of  the  malignant  disease  or  by  tlie  accumulation  of  foreign 
bodies  or  solid  fecal  masses  above  the  seat  of  constriction,  the  fecal 
passage  is  completely  arrested. 

An  interstitial  tumor  may  give  ri.se  to  intestinal  obstruction 
independently  of  invagination  or  stenosis  sufficient  in  degree  to 
intercept  the  fecal  current  by  interfering  with  normal  peristaltic  con- 
tractions. While  both  benign  and  malignant  tumors  are  relatively 
frequent  in  certain  parts  of  the  intestinal  canal,  the  small  intestine  is 
quite  exempt,  with  the  exception  of  the  portion  where  the  bile  and 
pancreatic  ducts  enter  the  duodenum,  in  which  locality  carcinoma  and 
sarcoma  are  quite  common.  Tiie  cecum,  the  sigmoicl  flexure,  and 
the  rectum  are  the  portions  of  the  large  intestine  most  freciucntly  the 
seat  of  tumors,  both  benign  and  malignant.  In  infants  and  children 
the  .seat  of  obstruction  from  tumors  is  more  frequently  above  than 
below  the  ileocecal  valve  ;  in  the  adult  and  aged,  at  and  below  that 
point. 

Benign  Tumors. — Benign  tumors  of  the  intestinal  walls  are  not 
uncomm<jn,  but  they  rarely  reach  a  .size  to  cau.se  danger  to  life, 
con.sequently  the  diagnosis  is  usually  made  in  the  autop.sy  room. 

I.enign  polypoid  tumors  .seldom  attain  a  sufficient  size  to  give 
rise  to  intestinal  obstruction  unless  they  cau.se  additional  mechanical 
disturbances,  such  as  invagination  or  flexion,  conditions  (hat  have 
already  been  alluded  to.  If  the  tumor  alone  is  the  cau.se  of  ob.struc- 
tion,  it  is  removed  by  laparo-enterotomy. 

Leichtenstern  clas.sifies  benign  intestinal  tumors  as  follows: 

I.  Fibromata  that  originate  in  the  submuco.sa  and,  by  their 
61 


962  TUMORS. 

growth  in  the  direction  offering  least  resistance,  protrude  into  the 
lumen  of  the  bowel  as  fibroid  polypi,  which  may  cause  intestinal 
obstruction  by  occlusion  or  invagination. 

2.  Myomata,  starting  in  the  muscularis  mucosae,  in  some  cases 
very  vascular  (angiomyomata),  in  other  cases  more  fibrous  (myo- 
fibromata)  ;  the  latter  project  into  the  intestine  as  polypi  and  give 
rise  to  the  same  mechanical  disturbances  as  fibromata  similarly 
located. 

3.  Submucous  lipomata,  which  may  present  themselves  as  pedun- 
culated tumors  in  the  intestinal  canal,  but  seldom  attain  a  size  suffi- 
cient to  cause  obstruction.     These  tumors  are  often  multiple. 

4.  Mucous  polypi,  papillomatous  or  with  a  smooth  surface. 

As  to  the  frequency  of  intestinal  polypi  of  all  the  different  his- 
tologic varieties  and  their  anatomic  location,  Leichtenstern  gives  the 
following  table  : 

Rectum  (estimate  too  low) ' 75 

Colon 10 

Cecum 4 

Ileocecal  valve 2 

Lower  portion  of  the  ileum  (usually  found  by  causing  invagination)    .  30 

Jejunum 5 

Duodenum 2 

Virchow  states  that  myomata  are  rare,  and,  if  we  exclude  uncer- 
tain observations,  develop  only  into  small  tumors.  He  has  found 
these  tumors  only  in  the  small  intestine.  He  describes  a  specimen 
from  the  Berlin  Museum,  of  a  tumor  the  size  of  a  cherry-stone  in 
the  transverse  portion  of  the  duodenum.  It  was  clad  with  mucous 
membrane  and  had  undergone  calcareous  degeneration,  and  pro- 
truded into  the  lumen  of  the  intestine.  Microscopic  examination 
showed  that  the  tumor  was  composed  of  connective  tissue  and 
muscle-fibers,  and  that  it  was  connected  with  the  muscularis  of  the 
intestine. 

He  also  states  that  submucous  lipomata  are  found  in  the  stom- 
ach, jejunum,  and  colon.  They  may  become  pedunculated,  and 
the  large  polypi  of  the  jejunum  are  usually  pedunculated  lipomata 
that  push  the  mucosa  before  them  and  that  often  extend  for  an  inch 
into  the  intestine.  Innocent  in  themselves,  they  may  give  rise  to 
intussusception,  but  Virchow  does  not  state  that  they  have  ever 
caused  occlusion  by  their  size  alone. 

Wesener,  to  whom  we  are  indebted  for  a  careful  and  exhaustive 
review  of  the  literature  of  the  subject,  found,  in  the  Pathologic  Mu- 
seum of  Giessen,  a  round  tumor  of  the  duodenum  the  size  of  an  apple. 
It  was  located  in  the  posterior  wall  of  the  duodenum,  five  centimeters 
above  the  entrance  of  the  bile-duct ;  but  the  large  mass  of  the  tumor 
extended  into  the  peritoneal  cavity  and  protruded  only  slightly  into 
the  lumen  of  the  intestine.  Behind  the  tumor  were  the  pancreatic 
and  bile-ducts,  which,  however,  were  not  compressed.  On  micro- 
scopic examination  this  tumor  was  found  to  be  a  myoma. 

Wesener  also  found  a  myoma  of  the  duodenum  in  the  following 


OPERATION. 


963 


case  :  A  man,  fifty-five  years  of  age,  had  suffered  frcim  gonorrheal 
cystitis  and  chronic  polyarthritis,  and  toward  the  end  of  his  hfe  pre- 
sented indistinct  symptoms  of  intestinal  disturbance,  constipation 
alternating-  with  diarrhea,  and  occasional  attacks  of  copious  vomit- 
ing that  persisted  for  two  or  three  days  and  then  disappeared,  to 
recur  after  a  short  time.  The  increasing  emaciation  for  the  last  few 
months  before  the  patient  died  caused  the  diagnosis  of  carcinoma  of 
the  stomach  to  be  made,  though  neither  tumor  nor  coffee-ground 
vomiting  was  observed.  The  autopsy  showed  a  dilated  stomach, 
together  with  dilatation  of  the  p)'lorus  and  the  upper  portion  of  the 
duodenum,  but  no  carcinoma.  Fifteen  centimeters  below  the  pj'lorus 
a  nodular  tumor  the  .size  of  a  plum  protruded  into  the  intestine.  On 
its  apex  was  a  depression  with  loss  of  substance,  where  the  mucous 
membrane  was  wanting.  The  tumor  in  the  duodenum  was  part  of 
a  larger  tumor,  the  size  of  a  fist,  situated  outside  of  the  intestine, 
between  the  duodenum  and  the  transverse  colon,  lying  on  the  atro- 
phied pancreas,  to  the  head  of  which  it  was  adherent.  Microscopic 
examination  showed  the  tumor  to  be  a  myoma  that  had  originated 
in  the  circular  fibers  of  the  muscularis  of  tiie  intestine  without  caus- 
ing absolute  obstruction.  The  tumor  had  evidently  caused  a  certain 
degree  of  stenosis,  as  was  shown  by  the  dilatation  of  the  duodenum 
and  the  stomach  above. 

A  very  interesting  case  of  myoma  of  the  ileum  was  reported  b)' 
Christian  Fenger,  in  11894,  in  a  very  valuable  pai)er  on  "  Benignant 
Tumors  of  the  Ileum,"  from  which  I  have  obtained  important  inft)r- 
mation. 

The  patient  was  a  man  seventy-five  years  of  age.  His  family  liistory  was  negative. 
General  health  always  good  until  a  year  before,  when  he  had  oc:casional  attacks  of  con- 
stipation unattended  by  vomiting.  During  the  last  five  or  six  weeks  bowels  have  moved 
but  slightly  and  the  stomach  lias  refused  food,  or,  after  eating,  he  would  experience  a 
sense  of  heaviness,  followed  by  nausea.  Occasionally  an  hour  or  two  after  eating  he 
vomited,  sometimes  fecal  matter.  During  the  last  two  weeks  lie  has  vomited  alrnosi  every 
day — first  the  stomach-contents,  then  the  contents  of  the  bowels.  Paroxysmal  jiain  in  the 
abdomen,  the  paroxysms  becoming  more  frequent.      No  pus  or  blood  in  the  feci's. 

Examination. — Patient  in  bed,  old,  pale,  <lecrepit,  emaciated.  AJKlomen  not  tym- 
panitic, but  when  a  paroxysm  of  pain  occurred,  |)cristaltic  contraction  of  intestinal  coils 
could  be  seen  through  the  thin  abdominal  wall.  No  hernia  and  no  tumor  could  be  seen 
or  felt.      Rectal  examination  negative. 

Diagnosis. — Chronic  intestinal  obstruction  from  carcinoma,  probably  of  hngc  intes- 
tine, high  up  in  the  sigmoid  or  in  the  right  flexure  of  colon. 

Operation. — An  incision  three  inch(-s  in  length  was  made  in  the  median  line  below 
the  umbilicus,  and  the  peritoneum  sutured  to  the  skin.  'I'lu-  loops  of  small  intestine  (hat 
came  into  view  were  neither  injected  nor  dilated.  .-Xbdominal  exi)loralion  revealed 
nothing  abnormal  in  the  rectum  or  colon.  On  examining  the  small  inteslinc  a  small 
round  tumor,  about  the  size  of  a  walnut,  was  felt.  The  inleslinal  wall  over  the  lumt>r 
was  somewhat  thickened  and  movable,  but  the  tumor  could  not  be  dislcHlgcd,  Alli-ni|)ls 
in  this  directirjti  caused  traction  ui>on  the  basir  of  the  tumor.  it  was  situated  on  the  side 
of  the  hx>p,  midway  between  the  convex  border  and  ihe  mesenteric  attachment  The 
loop  was  em|>tied  to  a  distance  of  five  inches  on  ea(  h  side  of  the  tumor,  and  a  strip  of 
iodoform  gauze  pushed  througli  the  mesentery  ami  tied,  so  as  t(»  exclude  feces  from  the 
loop.  A  longitudinal  incision,  an  inch  and  a  half  long,  was  made  over  the  tumor,  which 
was  then  enucleated  with  ease.  It  was  stn(»oth,  cylindric,  rounded,  45  mm.  long  and 
28  mm.  in  diameter,  clad  with  mucosa,  dark  at  the  routi(!<<l  end.  and  yellowrsh  (rom 
imbibition  of  bile  coloring-matter  from  feces.  As  the  base  or  |)edi(  le  of  the  tumor,  which 
was  lyi  cm.  in  diameter,  extend(rd  beyond  the  line  of  incision,  the  Jailer  was  prolonged 
to  the  base,  which  was  excised,  leaving  a  irnnsvei^t;  incision  one  incii  in  diameter. 


964  TUMORS. 

The  T-shaped  intestinal  wound  was  now  united  by  step  sutures,  first  a  continuous 
silk  suture  from  the  distal  end  of  the  longitudinal  to  the  transverse  wound,  and  the  trans- 
verse wound  united  by  interrupted  sutures  passed  through  the  mucosa  only.  Interrupted 
Lambert  sutures  were  then  introduced  through  the  serosa  and  muscularis  to  bury  the 
mucosa  sutures,  especial  care  being  taken  at  the  angles  of  the  wound. 

Examination  of  the  intestine  as  to  its  permeability  for  feces  and  gases  now  revealed 
an  indentation  on  the  side  of  the  intestine  opposite  to  the  base  of  the  incision,  indicating 
that  one  of  the  mucosa  sutures  had  caught  the  mucosa  on  the  opposite  side  of  the  intes- 
tine. The  sutures  of  the  transverse  wound  were  therefore  loosened,  and  the  opposite 
wall  of  the  intestine  freed  by  division  of  the  offending  suture.  The  transverse  wound 
was  then  reunited  by  mucosa  and  seromuscular  sutures  as  before,  and  the  loop  flushed 
with  sterilized  water. 

The  iodofoiTn  gauze  strips  which  compressed  the  loop  above  and  below  were  removed, 
and  the  permeability  of  the  intestine  as  to  feces  and  gases  again  tested.  It  was  found 
that  the  intestine  was  entirely  permeable  at  the  place  of  operation  and  that  at  the  line  of 
sutures  the  intestine  was  air-tight.  The  intestine  was  now  flushed  again  with  sterilized 
water.  An  omental  flap  was  then  made  by  pulling  down  the  omentum,  which  was  fol- 
lowed by  the  transverse  colon.  The  omentum  was  not  quite  long  enough  to  go  around 
the  loop  without  some  compression,  but  it  was  brought  around  and  sutured  to  both  sides 
of  the  mesentery.  The  loop  in  the  field  of  operation  and  the  omental  flap  were  now 
anchored  by  sutures  to  the  parietal  peritoneum  at  the  lower  border  of  the  wound,  and  an 
iodoform  gauze  drain  laid  down  to  the  base  of  the  loop.  The  remainder  of  the  abdom- 
inal wound  was  then  united  in  the  usual  manner. 

The  operation  occupied  about  an  hour  and  a  half.  At  its  close  the  patient  was  in 
good  condition  ;  pulse  no  and  strong.  He  made  a  good  and  uneventful  recovery  and 
is  at  this  time,  sixteen  months  later,  well. 

Microscopic  examination  of  the  tumor  proved  its  myomatous  structure. 

That  myoma  is  by  no  means  limited  to  the  small  intestine  is  well 
shown  by  a  case  of  myofibroma  of  the  rectum  that  came  under  my 
observation  a  few  years  ago.  The  tumor  had  reached  the  size  of  a 
child's  head,  was  pedunculated  in  the  direction  of  the  peritoneal 
cavity,  and  evidently  subserous  in  its  primary  anatomic  starting- 
point. 

Intraperitoneal  Myofibroma  of  the  Rectum. — This  case  is 
described  somewhat  in  detail,  for  the  purpose  of  showing  how  diffi- 
cult it  is  in  some  cases  to  determine  beforehand  the  primary  location 
and  starting-point  of  solid  intrapelvic  tumors,  and  at  the  same  time 
to  point  out  the  impossibility,  by  present  means  of  diagnosis,  of 
differentiating  between  intraperitoneal  myofibroma  of  the  rectum  pro- 
jecting into  the  peritoneal  cavity  and  solid  tumors  of  the  ovary  and 
broad  ligament,  and  pedunculated  myofibromata  of  the  uterus.  I 
have  not  been  able  to  find  a  similar  case  in  the  literature,  although 
a  careful  search  has  been  made  dating  back  for  at  least  twenty  years. 

The  patient  was  a  married  woman  aged  forty-five,  the  mother  of  seven  children.  A 
pelvic  tumor  the  size  of  a  walnut  was  accidentally  discovered  by  her  family  physician. 
Dr.  Philler,  of  Waukesha,  while  attending  her  for  miscarriage  about  three  years  before 
she  came  under  my  care.  The  tumor  at  that  time  was  felt  between  the  uterus  and  rec- 
tum, and  appeared  to  be  firmly  attached.  For  two  years  it  caused  no  inconvenience  and 
the  patient  remained  in  her  usual  health  ;  at  the  end  of  this  time  the  abdomen  gradually 
commenced  to  enlarge  and  the  patient  to  complain  of  some  pelvic  distress  Six  months 
later  her  general  health  began  to  decline,  accompanied  by  want  of  appetite  and  consid- 
erable loss  of  flesh.  The  patient  never  suffered  from  constipation  or  any  other  symptom 
pointing  to  the  rectum  as  the  primary  seat  of  the  tumor.  Menstruation  normal,  both  as 
to  time  and  quantity  She  was  admitted  into  the  hospital  April  20,  1890,  at  which  time 
she  was  anemic,  considerably  emaciated,  the  abdomen  greatly  distended  by  fluid,  and 
both  lower  extremities  and  the  hips  edematous.  A  careful  examination  of  the  heart 
and  liver  revealed  nothing  that  could  account  for  the  ascites,  and  with  the  exception  of 
being  scanty,  the  urine  was  found  normal.   The  supposition  was  that  the  ascites  was  caused 


INTRAPERITONEAL    MYOFIBROMA    OF    THE    RECTUM.  965 

either  by  malignant  disease  of  one  of  the  abdominal  organs  or  by  tubercular  peritonitis. 
A  pailful  of  a  clear  serous  fluid  was  removed  by  tapping.  As  the  abdomen  was  being 
emptied  a  large  solid  tumor  became  apparent,  occupying  the  left  and  lower  portion  of  the 
abdomen.  Bimanual  examination  of  the  uterus  revealed  this  organ  to  be  of  normal  size 
but  displaced  to  the  right  and  pushed  or  drawn  upward  by  the  solid  tumor.  It  could  be 
clearly  established  that  no  direct  connection  or  adhesion  existed  between  the  uterus  and  the 
tumor.  The  right  ovary  could  be  detected  in  its  proper  location  and  of  normal  size.  The 
left  ovary  could  not  be  discovered.  It  was  now  evident  that  the  tumor  was  the  same  that 
had  been  discovered  three  years  before,  and  that,  in  all  probability,  it  was  the  cau.se  cf 
the  ascites.  The  tumor  was  quite  movable  and  could  be  pushed  from  the  vao-jna  in  an 
upward  direction  for  several  inches,  and  could  also  be  rotateil  around  its  axis,  but  when 
released,  would  always  return  to  the  same  position.  The  attached  portion  appeareil  to 
be  low  down  in  the  pelvis.  A  probable  diagnosis  of  a  solid  tumor  of  the  ovary  or  broad 
ligament  on  the  left  side  was  now  made,  and  a  radical  operation  advised. 

Laparotomy  was  performed  April  24,  1890.  Although  only  four  days  liad  inter- 
vened between  the  time  of  the  tapping  and  the  operation,  the  abdomen  had  again  become 
distended  by  a  large  quantity  of  the  same  kind  of  fluid.  An  incision  sufticiently  large  to 
permit  the  introduction  of  the  hand  was  made  half-way  between  the  umbilicus  and  pubes. 
After  all  the  serum  had  escaped  the  relation  of  the  tumor  to  the  uterus  and  its  adnexa 
was  carefully  examined.  The  uterus  was  found  normal  in  size,  but  displaced  upward 
and  to  the  right  by  the  tumor.  The  right  ovary,  tube,  and  broad  ligament  could  be 
readily  identified,  and  were  found  to  be  normal  in  size  and  structure  ;  they  had  no  con- 
nection whatever  with  the  tumor.  The  tumor  was  hard  to  the  touch  and  evidently  cov- 
ered with  peritoneum.  No  adhesions.  In  searching  for  its  attachment  it  was  ascertained 
that  its  pelvic  porticms  became  more  and  more  contracted,  until,  at  the  deei)est  portions 
of  the  pelvis,  near  the  middle  line,  the  attached  part  was  .somewhat  flattened  in  a  vertical 
direction,  and  about  three  limes  the  diameter  of  the  first  joint  of  the  thumb.  On  account 
of  the  inaccessibility  of  tlie  attached  portion  no  attempt  was  made  to  remove  the  tumor 
by  enucleation  lest  hemorrhage  be  encountered.  It  was  im[)ossible  to  ligate  the  base  of 
the  tumor  without  lifting  it  partly  out  of  the  pelvis,  which  was  done  by  an  assistant.  It 
was  intended  to  tie  the  contracted,  attached  part  in  three  sections — the  upjier  and  lower 
parts  by  transfixion,  the  central  portion  by  throwing  the  ligature  around  it  after  cut- 
ting the  tied  sections.  As  soon  as  the  transfixed  portions  had  been  cut  and  the  last  liga- 
ture was  to  be  applied,  the  tumor  was  torn  out  of  its  bed  by  the  traction  made  by  the 
assistant.  Immediately  upon  the  removal  of  the  tumor  a  small  quaiilily  of  fluid  feces 
escaped  into  the  pelvis,  which  was  at  once  carefully  removed  with  a  sponge,  and  the 
surface  compressed  to  prevent  extravasation,  until  it  could  be  determined  what  had 
occurred. 

Upon  examination  of  the  torn  surface  of  the  tumor  a  stri])  of  mucous  membrane  was 
seen,  somewhat  oblong  in  shape,  about  half  an  inch  in  length  and  one-third  of  an  inch 
in  width.  The  escape  of  feces  left  no  doubt  that  some  part  of  the  large  intestine  Iiad 
been  injured,  but  some  doubt  existed  as  to  the  exact  location  of  the  wound.  Rectal 
insufflation  of  air  demonstrated  that  the  opening  was  at  the  floor  of  the  jielvis,  at  a  point 
over  the  middle  of  the  rectum,  where  the  pcriti^neum  is  reflected  forward  over  ihe  blad- 
der. A  large  soft-rubber  tube  was  now  inserted  into  the  rectum  as  far  as  the  sigmoid 
flexure  of  the  colon,  and  over  this,  after  careful  disinfection  of  the  parts  which  had  been 
contaminated  with  feces,  the  opening  in  the  rectun)  was  closed  with  a  number  of  Lem- 
bert  sutures.  This  part  of  the  oi)eration  was  exceedingly  difficult  and  somewhat  unsatis- 
factory, on  account  of  the  deep  location  of  the  visceral  wound.  After  another  careful 
toilet  of  the  pelvic  cavity  a  large  Keith's  glass  drain,  surroun<le(l  by  several  layers  of 
iodoform  gauze,  was  inserted  in  such  a  manner  that  its  distal  end  corresponded  exactly 
with  the  sutured  rectal  wound.  The  abdominal  incision,  which  extended  from  the  pubes 
to  the  umbilicus,  was  closed  in  the  usual  manner,  except  at  the  lower  angle,  where 
enough  space  was  left  open  for  the  capillary  glass  drains.  The  operation  was  net'essarily 
a  protracted  one,  lasting  nearly  two  hours,  and  toward  the  latter  part  of  it  the  jjulse 
became  very  feeble  and  rapid,  the  patient  at  the  same  time  manifesting  other  .symptoms 
of  shock  ;  whisky  had  to  be  administered  subcutaneously. 

The  i)atient  rallied  well  from  the  imtn«Mliatc  effects  of  the  (jperalion.  The  bladder 
was  emptied  by  the  use  of  the  catheter,  and  small  doses  of  ojmini  were  given  to  procure 
rest  for  the  rectal  wound.  During  the  first  forty  right  hoius  nothing  was  given  by  the 
stomach  but  brandy  in  water  and  beef  tea.  Very  little  fluid  (•s(ai)ed  llnniigli  the  driiin- 
age-tube,  but  this  was  allowed  to  remain  for  the  jnirpose  of  guarding  again.sl  fei  iil  extra- 
vasation should  the  rectal  wound  fail  to  heal  by  primary  intention.  A  luxalive  was 
administered  on  the  third  day,  and  after  the  bowels  had  moved  freely,  the  glass  drain  wnn 
removed  and  a  small  quantity  of  fluid  feces  escaped.  The  tubular  wound  was  gently 
washed  out   by  irrigation  with    a  solution  of  boric  acid,  and   the  ilrain  reinserted.      I  lie 


966  TUMORS. 

external  wound  healed  without  suppuration,  and  all  the  sutures  were  removed  at  the  end 
of  the  first  week.  Six  days  after  the  operation  tlie  glass  tube  was  removed,  and  drainage 
was  secured  by  the  insertion  of  strips  of  iodoform  gauze  down  to  the  rectal  wound.  The 
fecal  fistula  closed  completely  and  permanently  two  weeks  after  the  operation,  after  which 
the  drainage  opening  closed  rapidly  by  granulation  and  cicatrization.  Ascites  did  not 
reappear  after  the  operation,  and  the  patient  has  remained  in  excellent  health  since  the 
operation. 

Description  of  Twnor. — The  tumor  weighs  twelve  pounds.  It  is  somewhat  irregu- 
lar in  outline,  but,  on  the  whole,  it  is  nearly  globular.  It  is  covered  by  peritoneum, 
except  at  the  base,  where  it  was  detached  from  the  rectum.  At  the  margins  of  the 
attached  surface  it  is  easy  to  trace  the  tumor  between  the  mucous  membrane  and  the 
peritoneal  coat  of  the  anterior  rectal  wall.  The  tumor  is  very  dense  throughout,  and  the 
cut  surface  presents  the  trabeculated  structure,  with  multiple  foci  of  growth,  so  charac- 
teristic of  myofibroma.  Under  the  microscope  it  can  be  seen  that  the  fibrous  tis.sue  pre- 
dominates, the  fibers  being  arranged  in  concentric  layers  and  wavy  bundles  traversing 
the  tumor  in  different  directions.  The  muscular  fibers,  with  their  elongated  large  nuclei, 
are  arranged  in  bundles.  The  tumor  tissue  is  .scantily  supplied  with  blood-vessels.  The 
manner  of  attachment  of  the  tumor,  as  well  as  its  microscopic  structure,  leave  no  doubt 
that  it  is  a  myofibroma  which  started  in  the  anterior  rectal  wall,  probably  somewhat 
nearer  the  peritoneal  than  the  mucous  coat. 

That  an  intraperitoneal  myofibroma  of  the  rectum  must  be  an  exceedingly  rare  affec- 
tion is  evident  from  the  fact  that  no  similar  case  could  be  found  in  literature.  A  friend 
of  mine,  who  related  this  case  to  Sanger,  of  Leipzig,  stated  that  the  latter  had  observed 
a  somewhat  similar  case,  but  it  has  evidently  not  been  published.  Myofibroma  of  the 
rectum  projecting  into  the  lumen  of  the  bowel  as  a  polypoid  growth,  if  not  common,  is 
at  least  occasionally  met  with.  Quite  a  number  of  operations  for  this  affection  could  be 
collected.  In  such  cases  the  primary  starting-point  of  the  tumor  must  be  near  the  mu- 
cous membrane,  which  is  pushed  before  it  and  becomes  the  covering  of  the  polypus.  If 
the  primary  matrix  of  the  tumor  is  located  nearer  the  serous  coat,  the  tumor  projects  in 
the  direction  offering  the  least  resistance,  and  becomes  an  intraperitoneal  growth,  con- 
striction and  pedunculation  taking  place  at  the  attached  portion  as  the  tumor  enlarges 
within  the  peritoneal  cavity.  It  might  be  claimed  that  the  tumor  was  primarily  a  myo- 
fibroma of  the  uterus,  becoming  later  attached  to  the  rectum,  and  isolated  from  the  uterus 
by  progressive  atrophy  of  the  pedicle.  Such  an  explanation  is  untenable  in  this  case, 
because  at  the  margin  of  the  attached  portion  it  is  easy  to  trace  the  tumor  substance 
between  the  peritoneal  and  mucous  coats  ;  at  the  same  time,  the  surface  of  the  uterus  on 
the  corresponding  side  was  found  intact  and  perfectly  smooth. 

In  a  second  case  I  removed  a  myofibroma  the  size  of  a  walnut  from  the  anterior 
rectal  wall,  through  an  incision  of  the  posterior  vaginal  wall.  This  tumor  reached 
down  to  the  mucous  membrane  of  the  rectum,  but  projected  toward  the  vagina ;  if  it  had 
been  located  about  two  inches  higher  up,  it  would  have  gradually  developed  into  an 
intraperitoneal  tumor. 

Heurtaux,  of  Nancy,  reports  two  cases  of  myoma  of  the  intes- 
tine that  came  under  his  own  observation.  In  his  first  case  the 
tumor  had  twice  given  rise  to  attacks  of  intestinal  obstruction,  the 
interval  between  the  first  and  the  second  attack  being  nine  years. 
At  the  time  the  third  attack  occurred  the  patient,  a  woman,  had 
reached  the  age  of  fifty.  This  time  the  attack  was  initiated  by  dis- 
tressing tenesmus.  In  the  ampulla  of  the  rectum  a  round  detached 
tumor,  the  size  of  an  apple,  with  surface  incrusted  with  lime  salts, 
could  be  felt.  Under  the  influence  of  an  anesthetic  the  tumor  was 
extracted,  and  its  myomatous  nature  was  demonstrated  by  micro- 
scopic examination.  During  the  first  attacks  the  patient  was  exam- 
ined by  Germain  See,  who  felt  a  swelling  under  the  liver  that  could 
not  be  felt  after  the  tumor  was  removed.  Heurtaux  believes  that 
the  tumor  developed  originally  in  the  large  intestine,  at  the  junction 
of  the  transverse  with  the  ascending  colon,  and  that  the  pedicle  gave 
way  spontaneously. 

The  second  patient  was  thirty-seven  5'ears  of  age,  and  had  been 


CYSTS. 


967 

subject  for  three  years  to  constipation  and  paroxysmal  colicky  pains 
and  for  the  last  month  tenesmus,  accompanied  by  mucous  bloody 
discharges.  Stools  normal  in  shape.  For  the  last  five  days  intes 
tmal  obstruction.  Immediately  above  the  sphincter  ani  an  e^cr. 
shaped  tumor,  the  size  of  a  pear,  with  smooth  surface,  could  be  felt 
attached  to  the  posterior  wall  of  the  rectum  bv  a  pedicle  the  size  of 
the  thumb.  Ligation  of  the  pedicle  and  rcmwal  of  the  tumor  were 
followed  by  recovery.  Microscopic  examination  again  proved  the 
myomatous  nature  of  the  tumor. 

A  few  cases  ha\e  been  reported  where  the  obstruction  was  caused 
by  cysts.  In  Buchwald's  case  the  symptoms  of  obstruction  were 
acute,  and  laparotom>-  was  performed  on  the  third  da\-.  The  [Patient 
was  a  box-  who  had  previously  been  in  good  health.  As  soon  as 
the  peritoneal  cavity  was  opened  two  c\-sts  attached  to  the  small 
intestine  presented  themselves  in  the  wound.  As  the  cysts  had  pro- 
duced a  sharp  flexion,  nine  centimeters  of  the  bowel,  including  the 
cysts,  were  resected  and  the  ends  united  by  circular  suturing. 
Twenty-seven  hours  after  the  operation  the  patient  died.  The  ne- 
cropsy showed  that  the  resected  piece  was  taken  from  the  jejunum, 
one-half  meter  below  the  duodenum.  One  cyst  measured  seventeen 
centimeters  and  the  other  ten  centimeters  in  diameter.  The  walls 
of  the  c\st  were  white  and  very  thin.  The  microscopic  examination 
showed  that  they  were  composed  of  the  same  tunics  as  the  bowel, 
but  the  mucous  membrane  was  atrophied  and  contained  no  gland.s.' 
The  cysts  communicated  with  each  other  and  the  lumen  of  the 
bowel.  The  latter  was  not  diminished  in  size.  The  cy.sts  contained 
a  yellowish  fluid  having  a  .strotig  odor  of  acetone.  Under  the  micro- 
scope the  contents  showed  c\lindric  cells  in  a  state  of  (jitty  degen- 
eration, chole.sterin  crystals,  granules  of  leucin.  fat  globules,  and 
rod-shaped  bacteria,  but  no  intestinal  contents.  He  believes  that 
the  cysts  had  no  connection  whatever  with  the  vitelline  duct. 

Kulenkampff  reports  the  ca.se  of  a  child  three  years  of  age,  who 
had  suffered  occa.sionally  from  colic  and  constijjation,  and  was  at- 
tacked suddenly  with  .symptoms  indicative  of  acute  intestinal  ob- 
struction. Abdomen  was  .somewhat  tympanitic,  but  no  swelling 
could  be  made  out  by  percu.ssion  and  palpatiou.  Tenderness  and 
slight  dullness  in  the  right  inguinal  region.  The  boy  died  on  the 
.second  day.  The  autop.sy  revealed,  as  the  cau.se  of  death,  a  cyst 
in  the" region  of  the  cecum.  The  cy.st  was  as  large  as  a  man's  fist, 
and  had  thin,  almost  transparent  walls.  It  showed  several  depres- 
sions, which  gave  it  the  appearance  of  being  composed  of  three  or 
four  parts.  It  was  located  in  the  mesentery  of  the  ileum,  about 
forty  centimeters  above  the  ileocecal  valve.  It  did  not  comnuini- 
cate  with  the  lumen  of  the  bowel,  and  contained  a  thin,  chocolate- 
colored  fluid.  The  mesentery  at  this  jmint  was  drawn  out  like  a 
string  and  encirch-d  a  loop  of  the  ileum.  Above  this  |)oint  the 
bowel  was  greatly  dist<nded.  Me  believed,  with  Roth,  that  the  cyst 
was  congenital  and  had  developed  from  ••  dieerilc  ulum  (»f  the  ileum. 


968 


TUMORS. 


As  a  rule,  such  cysts  are  located  on  the  convex  side  of  the  bowel, 
but  in  this  instance  it  occupied  a  position  opposite. 

At  first  sight  the  cyst  appeared  like  a  greatly  distended  loop  of 
the  intestine.  As  in  both  these  cases  the  cyst  had  produced  intes- 
tinal obstruction  by  secondary  mechanical  conditions,  the  operative 
treatment  of  the  obstruction  would  include  the  removal  of  the  pri- 
mary cause  and  the  correction  of  the  secondary  mechanical  difficul- 
ties. This  would  include  resection  of  the  bowel  at  the  seat  of  ob- 
struction, including  the  tumor  and  restoration  of  the  continuity  of 
the  intestinal  canal  by  circular  suturing. 

The  diagnosis  of  a  benign  intestinal  tumor  is  never  made  until 
it  causes  functional  disturbances,  and  even  then  seldom  amounts  to 
more  than  the  recognition  of  the  existence  of  a  mechanical  obstruc- 
tion, the  nature  of  which  is  seldom,  if  ever,  known  with  sufficient 
accuracy  to  permit  of  positive  and  correct  conclusions.  The  treat- 
ment is  usually  directed  toward  the  complications  caused  by  the 
tumor.  In  operations  for  invagination  caused  by  benign  tumors 
reduction,  if  it  succeeds,  is  followed  by  removal  of  the  tumor.  If 
the  invagination  is  irreducible,  the  tumor  constitutes  a  part  of  the 
intussusceptum  and  is  included  in  the  treatment  of  the  same. 

Pedunculated  tumors  in  the  lumen  of  the  intestine  are  removed 
by  enterotomy,  and  interstitial  tumors  by  enucleation. 

Malignant  Tumors. — The  malignant  tumors  are  sarcoma  and 
carcinoma,  the  former  being  found  more  frequently  above,  the  latter 
more  frequently  below,  the  ileocecal  valve.  Sarcoma  is  more  often 
a  disease  of  childhood  ;  carcinoma,  of  advanced  age.  A  sarcoma 
in  the  intestine,  like  one  in  any  other  organ,  primarily  starts  from 
an  embryonal  matrix  of  connective  tissue,  and  hence  it  always  has 
its  starting-point  in  the  wall  beneath  the  mucous  membrane,  while 
carcinoma,  being  an  atypical  proliferation  of  epithelial  cells,  com- 
mences either  in  the  mucous  membrane  or  in  its  glandular  append- 
ages. 

Sarcoma. — Sarcoma,  starting  primarily  in  the  intestinal  walls, 
is  comparatively  a  very  rare  disease.  Madelung  has  had  three 
cases  of  his  own  and  has  collected  eleven  others.  The  sarcoma  is 
generally  of  the  small  round-celled  variety,  but  occasionally  is 
composed  of  spindle-shaped  cells.  The  tumors  probably  always 
commence  in  the  submucous  tissue,  and  from  there  extend  to  the 
remaining  tissues  of  the  bowel.  The  muscular -layers  are  next 
attacked  ;  then  the  mucous  coat ;  rarely  the  peritoneum,  even  in 
those  cases  that  terminate  in  death  from  this  cause.  These  tumors 
give  rise  to  dilatation  of  the  intestine,  and  rarely,  if  ever,  cause  any 
stenosis  of  the  lumen.  In  some  cases  several  distinct  parts  of  the 
intestine  are  involved  simultaneously  by  the  disease.  The  regional 
metastasis  involves  the  mesenteric  glands  at  an  early  stage,  and  of 
the  distant  organs,  the  omentum,  liver,  and  kidneys  are  most  fre- 
quently involved.  As  regards  the  etiology  of  the  disease,  little  is 
known.      One  case  was  preceded  by  a  contusion  of  the  abdomen. 


SARCOMA.  ^6^ 

A  well-authenticated  case  of  congenital  sarcoma  of  the  small 
mtestme  has  been  reported  by  Carl  Stern.  The  dav  after  the  birth 
of  the  child  symptoms  of  intestinal  obstruction  set  in  which  con- 
tinued until  It  died  at  the  end  of  the  fourth  da^^  The  tumor  com- 
menced at  a  pomt  132  cm.  below  the  pylorus.'  and  involved  a  sec- 
tion of  the  intestine  45  cm.  in  length.  On  slitting  the  intestine 
open  the  tumor  appeared  as  a  marked  prominence  with  a  wide 
base.  Surface  of  tumor  covered  only  in  part  by  mucous  membrane 
1  he  microscope  showed  a  veiy  vascular  round-celled  sarcoma  uell 
exhibited  in  the  accompanying  illustration  (Fig.  529). 

Sarcoma  of  the  intestines  occurs  most  commonly  during  the  third 
and  fourth  decades  of  life.  In  Madelung's  statistics,  the  oldest 
patient  was  fifty-two  and  the  youngest  four.  All  were  males  except 
one.  The  diagnosis  is  always  difficult  and  frequenth-  doubtful 
Ihe  existence  of  rapidly  growing  tumors  in  the  abdomen,  which  at 
first  are  freely  movable,  together  with  progres.si\-e  emaciation  and 
loss   of    strength   in   young    persons,  may    point  to  this  affection 


Fig-  529 —Congenital  sarcoma  of  small  intestine  (after  C.  Stem). 

Alternating  diarrhea  and  constipation  occur.  Tiie  duration  of  life 
IS  short,  the  greater  number  dying  within  nine  months.  Little  can 
be  done  in  the  way  of  treatment.  If  abdominal  .section  has  been 
performed  to  confirm  the  diagnosis,  and  a  sarcoma  is  found,  a  radi- 
cal operation  is  justifiable  only  if  the  di.scase  has  not  extended 
beyond  the  intestinal  wall  and  if  the  patient's  strength  promises  to 
carry  him  over  the  immediate  effects.  Secondary  tumors,  however, 
appear  at  .so  early  a  stage  of  the  di.sease  that  the  surgeon  will  usu- 
ally find  him.sejf  under  the  necessity  of  either  closing  the  abdomen 
or  resorting  to  an  entero-anastomosis.  with  a  view  to  eliminating 
permanently  from  the  fecal  circulation  the  di.seasc-d  portion  of  the 
intestine.  Madclung  made  two  resections,  but  both  patients  (Vwd 
shortly  afterward.  Mikulicz  performed  an  operation  for  this  condi- 
tion ;  the  patient  left  the  hospital  in  twenty-ftiur  days,  tlu-  operation 
wound  having  healed.  No  further  oljservations  were  made  on  this 
case. 

Nicolaysen   reports  an  exceedingly  interesting  case  of  enterec^ 
tomy  for  a  .sarcomatous  .stenosis  of  the  small  intestine     The  patient 


970 


TUMORS. 


was  twenty-eight  years  of  age.  A  firm,  nodulated,  kidney-shaped 
tumor  could  be  felt  in  the  abdomen  below  the  umbilicus.  The 
growth  was  first  noticed  six  months  before,  when  it  was  as  large  as 
a  hen's  egg.  In  the  morning  the  tumor  usually  could  be  felt  under 
the  costal  arch,  while  during  the  day  it  descended  into  the  hypogas- 
tric region,  where  it  always  caused  more  pain.  As  the  symptoms 
of  obstruction  gradually  increased  in  severity  and  did  not  yield  to 
ordinary  treatment,  laparotomy  was  performed.  Median  incision' 
fourteen  centimeters  long.  It  was  found  somewhat  difficult  to  bring 
the  tumor  forward  into  the  wound.  The  tumor  occupied  the  mes- 
enteric side  of  the  bowel,  and  behind  it  a  number  of  enlarged  lym- 
phatic glands  could  be  felt.  Eighteen  centimeters  of  intestine,  in- 
cluding the  tumor  and  a  triangular  piece  of  mesentery,  were  excised, 
and  the  ends  of  the  intestine  united  with  sutures,  embracing  only 
serous  and  muscular  coats.  The  proximal  end  was  then  invaginated 
to  the  extent  of  two  centimeters,  and  the  invagination  retained  with 
five  Lembert  sutures,  over  which  the  peritoneum  was  once  more 
stitched  with  a  continued  suture  of  fine  catgut.  The  mesenteric 
wound  was  also  closed  by  suturing.  The  tumor  consisted  of  sev- 
eral nodules  the  size  of  a  goose  egg,  which  had  perforated  the  intes- 
tine. Microscopic  examination  of  the  tumor  and  lymphatic  glands 
showed  sarcomatous  tissue.     The  patient  recovered. 

Bessel-Hagen  describes  a  ver\'  similar  specimen  of  intestinal 
sarcoma  obtained  by  autopsy. 

A  boy,  seven  years  of  age,  after  a  trauma  suffered  from  a  rap- 
idly growing  tumor  in  the  abdomen  that  resulted  in  death  from 
marasmus  in  four  months.  At  the  autopsy  a  large  sarcoma  of  the 
jejunum  was  found  which  had  perforated  into  the  bowel  by 
necrotic  destruction  of  the  interior  of  the  tumor.  Microscopic 
examination  proved  it  to  be  a  small,  round-celled  sarcoma  that  had 
originated  in  the  submucosa  of  the  jejunum.  Multiple  metastases 
occurred  in  kidneys,  on  back,  and  in  the  lymphatic  glands.  Peri- 
tonitic  adhesions  had  caused  flexion  of  the  intestine  below  the 
tumor  and  dilatation  of  the  proximal  portion  from  ob.struction  thus 
produced.  As  a  sarcoma  of  the  intestine  gives  rise  only  to  symp- 
toms of  obstruction  and  consequent!}^  comes  under  surgical  treat- 
ment usually  after  extensive  infiltration  of  the  mesentery  and 
retroperitoneal  tissues  has  taken  place,  it  is  questionable  if  it  is 
prudent  to  attempt  a  radical  operation,  as  in  case  the  patient  re- 
covers from  the  operation  an  early  recurrence  is  almost  inevitable. 
If  a  sufficiently  early  diagnosis  were  possible,  resection  could  be 
made  with  a  fair  prospect  of  securing  a  permanent  result,  but  if  the 
infection  has  extended  to  the  tissues  around  the  bowel,  it  is  more 
judicious  to  leave  the  sarcoma  and  to  exclude  the  obstruction  by 
an  intestinal  anastomosis. 

Carcinoma. — In  most  cases  of  carcinoma  of  the  intestine  the 
disease  commences  in  the  mucous  membrane,  in  which  case  the 
parenchyma  of  the  tumor  is  composed  of  cells  that  resemble  the 


CARCINOMA. 


971 


columnar  epithelium  that  lines  the  intestinal   canal.      Carcinoma  is 
found  most  frequently  in   tiie  region   of   the  sigmoid   fle.xure,   the 


• :".,_  ^i:,-^-.'!^!' ■>!■';■'■,.''  '/■ 


.f^'g-  53°- — Periphery  of  cylindric-celled  carcinoma  of  the  ctcum  (  ,,  no)  (Surgical 
Clinic,  Rush  Medical  College,  Chicago):  a,  a.  Rows  of  carcinoma  cells  in  connective- 
tissue  spaces  ;  b,  intervening  connective  tissue. 


J''K-  53'- — Cylindric  celled  carcinoma  of  tlic  rectum  (  >(  480)  (Surgical  Clinic,  Rush 
Medical  College,  (,'hi(ago) :  <■/,  Connective-tissue  stroma  ;  h,  atypical  tubules  of  cMrcinoma  ; 
I,  cylindric  epithelial  cells. 

cecum,  and  rectum.      A  malignant  .st(  ii(»ms   m.iy  have  exi.stcd  for 
month.s    witliout   .symptoms,    when    suddenly   .symptoms    of   acute 


9/2  TUMORS. 

intestinal  obstruction  are  developed,  as  in  the  case  related  below. 
In  cases  of  acute  intestinal  obstruction  in  elderly  people,  where  no 
cause  for  it  can  be  found  in  the  abdomen,  a  thorough  rectal  examina- 
tion should  never  be  neglected.  During  one  of  my  visits  to  Zurich 
I  was  present  -at  a  very  interesting  autopsy  made  by  Klebs  upon 
one  of  Kronlein's  patients.  A  few  days  before,  a  woman  forty 
years  of  age  was  brought  into  the  hospital  presenting  well-marked 
symptoms  of  intestinal  obstruction  which  had  lasted  for  two  weeks. 
On  examination  no  cause  for  the  obstruction  could  be  found.  The 
abdomen  was  very  tympanitic,  rendering  palpation  difficult  and 
unsatisfactory.  Laparotomy  was  made,  but  as  nothing  could  be 
found  and  the  small  intestine  was  enormously  distended  through- 
out, inguinal  colostomy  was  performed.  The  operation  was  fol- 
lowed by  decided  relief,  the  abdomen  collapsed,  and  a  large  quan- 
tity of  feces  was  discharged  through  the  artificial  anus  ;  but  the 
patient  died  of  exhaustion  the  next  day.  At  the  postmortem 
examination  the  cause  of  the  obstruction  was  found  twenty  centi- 
meters below  the  artificial  anus,  in  the  shape  of  a  narrow  annular 
carcinomatous  stricture  of  the  colon.  In  his  remarks  on  the  case 
Kronlein  stated  that  he  had  observed  four  similar  cases  during  the 
time  he  had  been  in  Zurich.  It  is  not  unusual  that  such  a  stricture 
gives  rise  to  no  symptoms  until  suddenly  evidences  of  complete 
intestinal  occlusion  are  developed.  It  would  be  well  in  the  future, 
when  a  similar  condition  is  suspected,  to  explore,  if  need  be,  the 
upper  portion  of  the  rectum  and  lower  extremit}^  of  the  colon  as 
far  as  accessible,  by  Simon's  or  Kelly's  method,  as,  in  case  the  lesion 
is  recognized  and  accurately  located,  some  of  these  cases  will  be 
amenable  to  a  radical  operation  by  excision. 

The  difficulties  encountered  in  dealing  with  malignant  tumors 
of  the  intestinal  tract  are  made  very  apparent  by  Konig's  expei'i- 
ence.  He  gives  the  result  of  operations  in  13  cases.  In  3  of  these 
only  an  exploratory  incision  was  made,  as  it  was  found  that  removal 
of  the  tumor  was  impossible,  owing  to  extensive  adhesions  to  sur- 
rounding structures ;  no  obstructive  pressure  was  exerted  upon  the 
intestinal  tract.  In  3  other  cases  the  tumor  could  not  be  removed, 
but  as  it  produced  obstruction,  an  artificial  anus  was  made.  Of 
these  6  cases  i  died  of  peritonitis  in  six  days,  as  a  result  of  the 
operation  ;  2  were  living  ;  3  had  died  from  the  disease  in  from  four 
weeks  to  three  months  after  the  operation.  The  remaining  7  of  the 
13  cases  were  subjected  to  radical  operation  by  excision.  In  5  of 
these  the  excision  was  followed  by  circular  enterorrhaphy,  and  in  2 
by  the  formation  of  an  artificial  anus.  Of  these  patients,  4  died  as 
a  result  of  the  operation.  Of  the  5  circular  enterorrhaphies,  3  died, 
I  of  these  being  i  of  the  2  in  whom  an  artificial  anus  had  to  be 
made.  The  surviving  patient  with  an  artificial  anus  died  of  recur- 
rence of  the  carcinoma  one  year  after  operation.  Of  the  2  patients 
who  recovered  from  the  operation  of  resection  and  suture  both 
were  living — one  three  years   after  the  excision  of  a  carcinoma  of 


CARCINOMA.  n-?- 

the  ileum,  and  the  other  six  months  after  removal  of  an  obstructino- 
section  of  tubercular  intestine.  ^ 

Such  an  experience  by  a  master  in  surgery  is  certainl\'  not  well 
calculated  to  infuse  courage  and  confidence  in  the  average  suro-eon 
or  general  practitioner  in  dealing  with  intestinal  obstruction  du^e  to 
malignant  tumors.  Hopeless  as  these  cases  are  without  operation, 
any  rational  attempts  to  remove  the  disease  and,  if  this  can  not  be 
done,  to  make  an  entero-anastomosis  or  artificial  anus,  must  appear 
as  the  correct  and  only  course  to  pursue.  The  results  after  opera- 
tions for  malignant  disease  are  gradually  improving  and  will  con- 
tinue to  do  so  with  the  advancements  made  in  diagnosis  and  with 
the  improvements  of  the  technic  of  intestinal  operations.  If  a 
malignant  intestinal  tumor  give  rise  to  acute  intestinal  obstruction, 
the  risks  to  life  are  diminished  and  the  prospects  of  a  radical  opera- 
tion increased  by  meeting  the  urgent  s\mptoms  by  establishing  an 
artificial  anus  first,  and  postponing  the  removal  of  the  tumor  until 
the  intestines  are  in  a  better  condition  for  such  an  operation.  The 
same  holds  true  in  chronic  obstruction  that  has  resulted  in  great 
abdominal  distention  and  intestinal  paresis. 

Schede  is  of  the.  opinion  that  in  cases  of  complete  obstruction 
of  the  bowels  by  a  malignant  tumor,  excision  is  contraindicated,  as 
in  19  cases  of  intestinal  resection  for  malignant  disease,  of  6  cases 
in  which  the  occlusion  was  complete  all  died,  while  of  the  remaining 
13,  where  the  occlusion  was  onl\^  partial,  but  3  died.  These  statis- 
tics should  strongly  induce  us  to  endeavor  to  make  a  correct  diag- 
nosis before  urgent  symptoms  have  set  in  and  to  resort  to  operative 
treatment  at  a  time  when  the  general  condition  of  the  patient  is 
such  as  to  warrant  a  radical  operation,  and  the  local  conditions  at 
the  seat  of  obstruction  are  favorable  to  a  speedy  process  of  repair. 
If,  after  resection  of  the  lower  portion  of  the  colon,  it  is  found 
impossible  to  approximate  the  two  ends  of  the  bowel  and  the  distal 
end  is  not  sufficiently  accessible  to  make  an  intestinal  anastomosis 
or  lateral  implantation,  then  the  course  adopted  by  Gussenbauer  in 
one  of  the.se  cases  should  be  cho.sen.  This  ])atient  was  a  man  forty- 
six  years  of  age,  who  had  suffered  for  years  from  obstinate  consti- 
pation. On  examination  he  discovered  a  tumor  the  size  of  a  hen's 
egg  in  the  left  hyj)oga.stric  region,  two  fingerbreadths  below  a  line 
drawn  from  one  anterior  superior  spinous  process  of  the  ilium  to  the 
other.  The  tumor  could  also  be  felt  high  up  in  the  rectum  by 
pressing  it  downward  into  the  pelvis.  The  alxlomen  was  opened 
by  an  incision  over  the  tumor  j^arallcl  with  the  course  of  the 
descending  colon.  The  tumor  was  found  to  occupy  the  most 
prominent  portion  of  the  sigmcjid  flexure,  freely  movable,  and  not 
attached  to  any  of  the  surrounding  organs.  A  few  glands  behind 
the  affected  portion  of  the  colon  were  enlarged.  Circular  resection 
was  made,  including  a  corresponding  pr)rtion  of  the  mesocolon  and 
the  enlarged  lymphatic  glands.  On  account  of  too  ^reat  lo.ss  of 
sub.stance,  circular  enterorrhaphy  could  not  be  made,  con.scquently 


974  OBSTRUCTION    FROM    COMPRESSION. 

the  distal  end  was  closed  by  invagination  and  suturing  and  dropped 
into  the  abdominal  cavity,  while  the  proximal  end  was  sutured  into 
the  external  wound.  The  patient  made  a  good  recovery,  and  at 
the  end  of  ten  months  the  disease  had  not  returned.  Bull  reports 
two  cases  of  carcinoma  of  the  sigmoid  flexure  where  in  each 
instance  he  opened  the  abdomen  through  the  median  line  and 
stitched  the  descending  colon  into  the  wound  without  incising  it, 
reserving  this  step  of  the  operation  until  adhesions  had  taken  place. 
Both  patients  recovered.  In  one  of  these  cases  he  resected  six 
inches  of  the  colon,  including  the  artificial  anus  and  the  tumor, 
twelve  months  later,  and  the  patient  again  recovered  from  the 
operation.  At  the  time  the  report  was  made  the  operator  had  in 
view  a  third  operation  for  the  closure  of  the  second  artificial  anus, 
which  was  made  at  the  close  of  the  second  operation.  In  all  cases 
where  the  seat  of  obstruction  can  be  located  in  the  cecum  or  colon 
before  the  operation  the  lateral  incision  should  be  selected,  as  it  will 
afford  better  access  to  the  seat  of  obstruction  than  a  median 
incision.  If  it  is  found  impossible  to  remove  the  obstruction,  one 
of  two  things  must  be  done  :  If  the  bowel  below  the  obstruction 
can  be  reached,  an  intestinal  anastomosis  is  made,  or  the  ileum  is- 
divided  just  above  the  ileocecal  valve,  the  distal  end  closed,  and  the 
proximal  end  implanted  into  the  bowel  below  the  seat  of  obstruction. 
If  resection  can  be  done  with  a  prospect  of  removing  all  the  dis- 
eased tissues,  it  should  invariably  be  practised  as  a  primary  radical 
operation,  and  if,  on  account  of  its  extent,  circular  enterorrhaphy 
can  not  be  done,  the  distal  end  is  permanently  closed,  and  the 
proximal  end  stitched  into  the  wound.  If  the  distal  portion  can  be 
reached,  the  continuity  of  the  intestinal  canal  is  restored  by  intes- 
tinal anastomosis  or  lateral  implantation.  If  the  seat  of  obstruction 
can  not  be  ascertained  before  the  operation  and  exploration  through 
a  median  incision  locates  it  in  the  cecum,  colon,  or  rectum,  it  may 
become  necessary  to  make  a  lateral  incision  if  a  radical  operation 
is  decided  upon,  and  when  this  appears  impossible  or  unjustifiable, 
an  intestinal  anastomosis  or  lateral  implantation  can  be  made 
through  the  median  incision.  If,  on  account  of  the  location  of  the 
obstruction,  either  of  these  operations  is  inapplicable,  an  artificial 
anus  should  be  established  in  the  right  or  the  left  inguinal  region, 
and  the  median  incision  closed  and  dressed  separately. 

OBSTRUCTION  FROM  COMPRESSION. 

Intestinal  obstruction  from  compression  of  the  lumen  of  the 
bowel  from  the  outside  by  tumors,  swellings,  and  inflammatory 
products  depends  in  its  clinical  manifestations  largely  on  the  length 
of  time  required  for  the  compressing  force  to  develop  mechanical 
obstruction.  The  slow  growth  of  benign  tumors  is  most  likely  to 
give  rise  to  chronic  obstruction,  while  malignant  tumors,  from  their 
more  rapid  growth,  give  rise  to  mechanical  obstruction  by  compres- 
sion in  a  shorter   time  and  with  more  speedy  succession  of  symp- 


TYMPANITES. 


975 


toms.  Inflammator}'  swellings  may  come  on  so  rapidly  that  com- 
pression from  this  source  may  result  in  acute  intestinal  obstruction. 
The  same  is  true  of  cases  of  sudden  retroversion  of  the  gravid 
uterus.  The  diagnosis  in  such  cases  is  usually  not  difficult,  as  the 
size  of  the  tumor  is  such  that  it  can  readih^  be  located  anatomic- 
ally, and  the  clinical  history  will  aid  us  in  determining  its  nature. 
The  treatment  in  such  cases  is  directed  mainl\-  toward  the  removal 
of  the  cause  of  obstruction.  In  compression  obstruction  caused 
by  inoperable  tumors,  the  formation  of  an  artificial  anus  is  indicated 
as  a  palliative  and  life-prolonging  operation. 

Dynamic  Obstruction. — A  number  of  pathologic  conditions 
are  known  to  produce  s\^mptoms  that  so  closely  resemble  intestinal 
obstruction  that  the  abdomen  has  been  repeatedh'  opened  in  such 
cases  with  the  expectation  of  removing  the  cause  of  the  obstruc- 
tion, but  no  occlusion  of  an\-  kind  could  be  found.  These  are  the 
cases  that  have  caused  the  greatest  difficult}-  in  diagnosis,  and  have 
often  brought  disappointment  and  reproach  upon  the  surgeon. 
The  obstruction  in  these  cases  is  not  caused  by  a  narrowing  of  the 
lumen  of  the  intestine,  but  by  suspension  of  the  d\'namic  forces 
that  propel  the  intestinal  contents,  and  which  result  in  accumula- 
tion of  the  feces  and  gases  in  the  paralyzed  portion  of  the  bowel, 
which  is  followed  b\'  distention  of  the  intestines,  constipation,  and 
ob.stinate  vomiting,  which  in  rare  cases  may  become  fecal.  Cir- 
cumscribed or  diffuse  paresis  of  the  intestines  is  cau.sed  either  by 
an  inflammatory  affection,  such  as  peritonitis  or  enteritis,  which 
produces  suspension  of  muscular  contractions  in  the  same  manner 
as  when  an  inflammatory  process  in  any  other  organ  affects  directly 
the  muscular  ti.ssue,  or  the  tunics  of  the  intestines  are  in  an  intact 
condition,  but  a  paralysis  has  resulted  from  reflex  causes.  Pitts 
narrates  two  cases  in  which,  after  reduction  of  a  strangulated  hernia, 
he  performed  laparotomy  on  account  of  ])er.sisting  symptoms,  and 
found  no  cau.se  for  the.se  symptoms  .save  that  presented  b\-  the  free 
but  lifeless  coil  that  had  been  liberated  too  late. 

The  contents  in  a  paretic  bowel  are  liable  to  undergo  fermenta- 
tive and  putrefactive  changes,  and  the  gases  that  are  dc\'elopeil 
during  such  changes  accumulate  and  cause  so  exten.sivc  a  tympa- 
nites that  the  latter  may  become  a  mechanical  cau.se  of  obstruc- 
tion. 

Tympanites. — Ca.ses  of  sudden  death  from  ob.struction  of  the 
intestines  and  stomach  by  rapid  accumulation  of  gas  have  been 
reported  by  Dechambre,  Mercier.  L'Pereyra,  anil  others.  The 
patients  were  generally  aged  persons,  or  young  prisons  during 
convalescence  from  protracted  diseases. 

Gueneau  de  Mus.sy,  in  a  clinical  lecture,  treats  of  the  mechanical 
effects  of  overdistention  of  the  .stomach  and  small  intestine  as  a 
cause  of  inte.stinal  ob.struction.  The  empt\-  portion  of  ilie  intes- 
tinal tract  may  become  impermeable  from  such  a  cau.se.  with  the 
inevitable   result — acute   intestinal    obstruction.      There  is  a   well- 


976  OBSTRUCTION    FROM    COMPRESSION. 

authenticated  case  on  record  where  enormous  distention  of  the 
stomach  by  gas  produced  such  a  result. 

The  lowest  portion  of  the  ileum  may  be  compressed  against 
the  ascending  colon  so  firmly  as  to  become  a  cause  of  complete 
mechanical  obstruction.  Proof  of  the  existence  of  such  a  mechan- 
ical condition  is  furnished  in  cases  of  extensive  tympanites  where 
the  introduction  of  a  rectal  tube  affords  no  relief  In  such  cases 
the  distention  increases  even  after  death.  I  have  also  furnished 
experimental  proof  The  cadaver  of  a  child  was  inflated  moderately 
through  the  esophagus,  after  which  the  esophagus  was  tied  and  a 
tube  was  introduced  into  the  rectum  and  its  distal  end  immersed 
under  water.  Pressure  upon  the  abdomen  expelled  the  air  through 
the  rectal  tube.  When  the  experiment  was  repeated,  but  with  still 
further  distention,  no  air  could  be  made  to  escape  through  the 
rectal  tube  by  compressing  the  abdomen.  On  opening  the  abdomen 
with  great  care  it  was  seen  that  the  lower  portion  of  the  distended 
ileum  was  pressed  against  the  ascending  colon  so  firmly  that  the 
communication  between  them  was  completely  interrupted.  From 
these  observations  it  can  readily  be  seen  how  the  formation  of  an 
intestinal  anastomosis  would  frequently  prove  the  means  not  only 
of  relieving  the  obstruction,  but  also  of  removing  its  cause. 

If  gas  is  present  in  the  peritoneal  cavity  as  the  result  of  putre- 
factive changes  of  the  products  of  peritoneal  inflammation,  it  presses 
the  liver  away  from  the  diaphragm  and  the  percussion  dullness  dis- 
appears completely  when  the  patient  lies  on  the  back.  In  distention 
of  the  abdomen  from  the  presence  of  gas  in  the  intestines  the 
diaphragm  and  liver  are  crowded  upward,  but  the  latter  remains  in 
contact  with  the  chest-wall,  and  the  area  of  liver  dullness  remains 
the  same,  but  is  displaced  in  an  upward  direction.  When  life  is 
threatened  by  tympanitic  distentions  of  the  abdomen  during  the  con- 
valescence from  acute  diseases,  the  symptoms  appear  very  rapidly 
and  death  results  from  mechanical  compression  of  important  organs. 
Puncture  of  the  distended  intestines,  followed  by  aspiration  and,  if 
need  be,  repeated  at  short  intervals,  is  positively  indicated  in  such 
cases.  There  can  be  no  doubt  that  in  many  cases  of  peritonitis 
attended  by  diffuse  and  excessive  tympanites  the  symptoms  that 
point  to  intestinal  obstruction  are  due  to  the  same  causes, — flexions 
and  compression, — and  such  cases  would  also  be  greatly  benefited 
and  sometimes  cured  by  the  same  treatment. 

Peritonitis. — Peritonitis  may  lead  to  symptoms  resembling  intes- 
tinal occlusion  in  different  ways,  according  to  the  extent  and  type 
of  the  disease.  In  extensive  plastic  peritonitis  the  immobilization  of 
a  considerable  portion  of  the  small  intestine  may  give  rise  to  per- 
sistent vomiting  and  absolute  constipation.  Again,  as  we  have  just 
seen,  arrest  of  the  fecal  circulation  may  be  caused  by  the  tympanites 
alone,  while  perforative  peritonitis  is  attended  by  a  local  and  general 
shock,  which  causes  intestinal  paresis  through  the  sympathetic 
nerves.      Heusner  has  observed  that  perforative  peritonitis  gives  rise 


CATARRHAL    AND    ULCERATIVE    ENTERITIS.  977 

to  disturbances  simulating  intestinal  obstruction  by  arresting  intes- 
tinal movements.  He  narrates  the  history  of  two  cases  of  this  kind 
where  the  symptoms  of  intestinal  obstruction  were  so  prominent  that 
laparotomy  was  performed.  In  both  cases  perforative  peritonitis, 
but  no  occlusion,  was  found. 

Henrot,  in  his  classic  monograph  on  pseudostrangulation,  de- 
scribes a  number  of  ca.ses  of  perforation  of  tiie  gall-bladder  and  the 
processus  vermiformis  where  the  symptoms  during  life  had  pointed  so 
strongly  to  the  existence  of  intestinal  obstruction  that  a  wrong  diag- 
nosis was  made  by  able  clinicians.  He  also  calls  attention  to  those 
cases  of  paralytic  obstruction  that  are  often  observed  after  herni- 
otomy and  in  cases  of  strangulation  of  the  appendix  vermiformis 
and  testicle.  The  intestinal  paresis,  where  it  is  not  the  result  of 
inflammation,  must  be  looked  upon  as  a  reflex  symptom. 

Physical  signs  and  symptoms  are  sometimes  utterly  inadequate 
to  enable  a  distinction  between  acute  intestinal  obstruction  and  dif- 
fuse peritonitis  to  be  made.  In  differentiating  between  these  two 
conditions  it  must  be  remembered  that  in  the  absence  of  a  swelling, 
absolute  constipation  and  fecal  vomiting  are  the  most  characteristic 
symptoms  of  obstruction,  and  that  in  peritonitis  the  pain  is  severe 
and  continuous,  with  diffuse  tenderness,  tympanites,  and  absence  of 
visible  intestinal  coils.  In  mechanical  obstruction  of  the  bowels  the 
temperature,  as  a  rule,  is  not  above  normal  unless  complications  have 
set  in,  while  in  peritonitis  a  rise  in  temperature  is  the  rule,  although 
in  some  of  the  gravest  cases  it  is  subnormal.  Many  cases  of  sup- 
posed recovery  from  intestinal  obstruction  without  operation  un- 
doubtedly were  cases  of  dynamic  obstruction,  and  the  recovery  was 
either  entirely  spontaneous  or  facilitated  by  means  that  assisted  in 
the  restoration  of  the  peristaltic  action.  In  185  i  a  patient  was  ad- 
mitted into  Dupuytren's  ward  with  well-marked  symptoms  of  acute 
intestinal  obstruction.  This  eminent  surgeon  gave  it  as  his  ofMnion 
that  without  an  operation  a  fatal  termination  was  inevitable,  but  the 
patient  objected  to  the  operation  and  was  transferred  to  another 
ward,  where  he  recovered  in  three  days  under  tlie  use  of  simple 
cathartics. 

Numerous  similar  cases  could  be  cited  in  illustration  of  the  diffi- 
culty of  differentiating  in  all  cases  between  mechanical  .strangulation 
or  occlu.sion  and  dynamic  obstruction. 

The  surgical  treatment  of  grave  cases  of  peritonitis  beyond  the 
reach-  of  successful  medical  treatment  is  now  generally  conceded 
and  accepted,  and  more  especially  in  ca.ses  in  which  the  di.sca.se  has 
resulted  in  dynamic  intestinal  ob.striiction.  Abdominal  .section, 
enterotomy,  evacuation  of  the  distended  [jaretic  intestines,  injection 
through  the  visceral  incision  of  an  ounce  or  more  of  saturated  solu- 
tion of  sulphate  of  magnesia  will  occasionally  save  a  life  that  other- 
wise would  be  surely  doomed. 

Catarrhal  and  Ulcerative  Enteritis. — I^)r  some  reasons  that  at 
present  are  difficult  to  explain  simple  catarrhal  enteritis  ami  cnxum- 
62 


P78  OBSTRUCTION    FROM    PARESIS. 

scribed  ulcerations  of  the  small  intestine  have  occasionally  been 
the  cause  of  rapid  accumulations  of  gas,  followed  by  symptoms  of 
intestinal  obstruction.  Mercier  has  recorded  a  case  where  a  patient 
died  after  a  brief  illness  during  which  all  symptoms  pointed  to 
the  existence  of  intestinal  obstruction,  including  complete  consti- 
pation and  fecal  vomiting.  The  necropsy  showed  no  stenosis  or  any 
other  form  of  mechanical  obstruction,  but  several  large  ulcers  in  the 
middle  of  the  ileum. 

Hosier  reports  a  case  of  acute  intestinal  obstruction  that  followed 
a  catarrhal  enteritis,  where,  on  postmortem,  no  primary  mechanical 
obstruction  could  be  found.  The  small  intestine  was  so  enormously 
distended  that  it  filled  the  entire  abdominal  cavity,  compressing 
the  ascending  colon  so  firmly  as  to  render  it  completely  imper- 
meable ;  the  transverse  colon  was  also  compressed,  but  to  a  less 
extent. 

Zimmermann  described  a  case  of  acute  intestinal  obstruction 
where,  during  life,  the  collapse  came  on  so  rapidly  that  it  resembled 
cholera.  The  bowels  remained  completely  constipated,  and  the  vomit- 
ing was  so  severe  and  persistent  that  on  the  seventh  day  it  became 
stercoraceous.  The  patient  lived  six  weeks.  At  the  necropsy  the 
small  intestines  were  found  enormously  distended  and  their  walls  were 
much  attenuated.  Colon  was  also  distended.  In  the  ileum  a  number 
of  small  ulcers  were  found  that  had  destroyed  the  entire  thickness  of 
the  mucous  membrane.  In  a  case  of  this  kind  Obalinsky  made  a 
laparotomy,  and  as  he  found  the  external  surface  of  the  lower 
portion  of  the  ileum  only  congested,  but  no  mechanical  obstruction, 
he  closed  the  external  incision  and  the  patient  recovered.  He  be- 
lieved that  in  this  case  there  were  typhoid  ulcers  that  caused  a  func- 
tional stricture  of  the  bowel  and  the  syrhptoms  that  induced  him  to 
open  the  abdomen. 

Traumatic  Paresis. — Local  shock  the  result  of  an  injury  may 
temporarily  suspend  peristalsis  and  cause  intestinal  obstruction. 

E.  H.  King  reports  a  case  of  dynamic  obstruction  following  a 
contusion  of  the  intestines,  where  laparotomy  was  made  on  the  third 
day. 

The  patient  was  a  boy  twelve  years  of  age,  who  was  kicked  in  the  abdomen  by  an 
unshod  horse.  The  point  of  impact  was  in  the  middle  line,  just  below  the  umbilicus. 
Pain  and  vomiting  followed  soon  after  the  injury  was  received.  Second  day,  pulse  120  ; 
temperature,  100.5°  F.  ;  abdomen  very  tender  and  decidedly  tympanitic.  Third  day, 
symptoms  much  worse  ;  temperature  fell  suddenly  to  97°  F.,  while  the  pulse  increased 
to  140.  Median  abdominal  section.  Intestines  dilated,  very  vascular,  presented  a 
sodden,  edematous  appearance,  and  were  covered  with  plastic  lymph.  No  gangrene, 
perforation,  or  sign  of  injury.  The  ileum  was  drawn  forward  into  the  incision  and  was 
punctured  with  a  trocar,  much  gas  and  a  pint  of  fluid  feces  being  evacuated  ;  the 
puncture  was  closed  with  one  Lembert  suture.  The  serum  in  the  abdominal  cavity  was 
mopped  out  with  a  sponge,  and  the  abdominal  incision  closed  in  the  usual  manner. 
Intestinal  antiseptics  were  given  internally  to  guard  against  subsequent  distention. 
Drainage-tube  removed  on  the  third  day.  Superficial  part  of  wound  separated  under 
tension,  but  was  united  later  by  secondary  sutures.      The  patient  made  a  rapid  recovery. 

There  are  cases  on  record  in  which  the  reduction  of  a  strangu- 
lated hernia  was  followed  by  intestinal  obstruction,  and   no  gross 


TRAUMATIC    PARESIS. 


979 


pathologic  changes  were  found  in  the  reduced  loop  on  abdominal 
section  or  postmortem  ;  hence  it  is  reasonable  to  assume  that  the 
obstruction  was  caused  by  paralysis  of  traumatic  origin.  Opinions 
on  this  point,  however,  are  at  variance  :  some  attribute  the  obstruc- 
tion to  paralysis,  others  claim  that  the  trauma  resulted  in  a  condi- 
tion of  the  intestinal  wall  that  permitted  the  passage  of  microbes, 
causing  inflammation  that  was  responsible  for  the  paralysis.  It  is 
in  dynamic  obstruction  of  this  kind  that  medical  treatment  has  met 
with  the  most  encouraging  results. 

In  several  cases  of  volvulus  in  which  the  intestinal  loop  was 
twisted  1 80  degrees  around  its  axis,  but  without  serious  pathologic 
changes,  Heidenhain  found  reposition  followed  by  temporary  paral- 
ysis and  persistence  of  the  obstruction.  The  question  arises,  whether 
the  paralysis  was  the  result  of  peritonitis  or  vascular  disturbances 
in  the  strangulated  loop. 

Morawek  has  shown,  by  his  examination  of  specimens  of  para- 
lytic ileus  following  strangulation,  that  the  paralysis  is  caused  by 
inflammation. 

Borchert  has  seen  three  cases  of  herniotomy  die  with  symp- 
toms of  peritonitis  and  obstruction,  although  no  signs  of  obstruc- 
tion were  observed  until  three  or  four  days  after  the  operation. 
Postmortem  showed  no  peritonitis.  Friedlander  assumed  that  death 
under  such  circumstances  was  caused  by  the  resorption  of  toxic 
alkaloids  from  the  intestinal  canal  through  the  damaged  mucosa  of 
the  strangulated  portion  of  the  intestine. 

Reichel  has  had  a  similar  experience.  He  is,  however,  of  the 
opinion  that  in  such  cases  peritoneal  infection  has  occurred  by  the 
migration  of  pathogenic  microbes  through  the  injured  intestinal 
loop.  Fatal  peritonitis  often  shows  no  signs  of  inflammation  on 
postmortem  examination. 

Heidenhain  is  of  the  opinion  that  the  paralysis  takes  place 
without  infection,  in  consequence  of  nutritive  disturbances  cau.sed 
by  the  strangulation.  He  believes  that  pa.ssage  of  microbes 
through  the  damaged  intestinal  wall  is  not  of  frequent  occurrence. 

Tavel  and  Lanz  found  the  serum  in  the  hernial  sac  sterile  in 
sixteen  cases  of  external  and  two  cases  of  internal  hernia,  and  in 
two  of  the  former  cases  the  strangulation  had  cau.sed  gangrene. 

Tietze  found  bacteria  in  the  serum  contained  in  the  hernial  sac 
in  four  out  of  nine  cases  of  intestinal  .strangulation.  In  two  cases 
only  the  .serum  in  the  peritoneal  cavity  couUl  be  examined  and  was 
found  sterile.  In  three  of  the.se  nine  cases  the  intestinal  loop  was 
gangrenous  and  yet  the  serum  in  the  hernial  .sac  was  free  from  bac- 
teria. Tavel  and  Lanz  maintain  that  the  fibrinoplastic  peritonitis 
found  in  such  cases  is  caused  by  the  passage  of  thc-nn'c  products 
from  the  intestine  through  the  injured  wall. 

Heidenhain  advi.ses  that  little  or  no  opium  should  be  given  after 
herniotomy  in  order  to  prevent  intestinal  i)aralysis.  Astley  Cooper 
also  opposed  the  use  of  opium  in  such  ca.se.s.      Dieffenbach  admin- 


980         INTESTINAL    OBSTRUCTION    AFTER    ABDOMINAL    SECTION. 

istered  an  emulsion  of  castor  oil  after  the  operation.  Kummell 
invariably  gives  a  laxative. 

Semmola  has  reported  the  case  of  a  man,  twenty  years  of  age, 
of  nervous  temperament,  in  whom,  after  the  occurrence  of  diarrhea, 
symptoms  of  intestinal  obstruction  appeared  ;  to  these  ischuria  was 
added.  Ordinary  treatment  was  without  avail,  and  laparotomy  was 
proposed.  From  the  suddenness  of  the  onset  of  the  symptoms  of 
obstruction  after  the  occurrence  of  diarrhea  ;  from  the  paroxysmal 
character  of  the  pain ;  from  coexistence  of  paralysis  of  the  bladder 
without  previous  disease;  and  from  the  neuropathic  tendency  of 
the  patient,  a  diagnosis  of  paralysis  of  the  bowel  was  made,  and 
the  application  of  the  constant  current  was  recommended.  The 
positive  pole,  attached  to  a  catheter,  was  introduced  into  the  rectum, 
and  the  negative  pole  stroked  upon  the  abdomen  in  the  course  of  the 
colon.  The  applications  were  made  for  from  eight  to  ten  minutes 
thrice  daily.  The  symptoms  gradually  improved,  and,  after  the 
ninth  application,  the  bowels  were  spontaneously  moved.  In  the 
course  of  ten  days  the  patient  was  completely  restored  to  health. 

Besides  electricity,  high  stimulating  enemata,  lavage  of  stomach, 
and  abdominal  compression  constitute  the  most  reliable  expectant 
treatment. 

INTESTINAL  OBSTRUCTION  AFTER  ABDOMINAL  SECTION. 

About  ten  years  ago  Olshausen  reported  several  cases  of  lapa- 
rotomy in  which  more  or  less  eventration  became  unavoidable 
during  the  operation.  A  few  days  after  the  operation  the  patients 
presented  all  the  appearances  of  an  attack  of  acute  intestinal  ob- 
struction, and  death  followed  in  from  five  to  ten  days  after  the  oper- 
ation. Olshausen  explained  the  symptoms  during  life  and  the  fatal 
termination  by  assuming  the  existence  of  intestinal  paralysis,  disten- 
tion of  the  bowel,  and  absorption  of  toxic  agents  from  the  intestinal 
canal.  During  the  eventration  the  intestines  became  engorged  by 
venous  hyperemia,  which  in  turn  again  was  followed  by  exudation 
and  transudation  into  the  tissues  of  the  bowel. 

Sebileau  reopened  the  abdomen  in  two  cases  of  acute  intestinal 
obstruction  after  laparotomy,  and  no  mechanical  occlusion  or  exuda- 
tion of  any  kind,  but  enormous  meteorism,  was  found.  He  attributes 
this  condition  to  intestinal  paresis  and  rapid  accumulation  of  gas. 
The  prophylactic  treatment  of  such  cases  is  more  important  than  the 
curative.  The  administration  of  a  brisk  cathartic  on  the  second  or 
third  day  after  the  operation  will  usually  prevent  tympanitic  disten- 
tion of  the  abdomen  by  stimulating  the  paretic  walls  to  active  mus- 
cular contractions,  and  by  removing  the  intestinal  contents,  the  source 
of  putrefactive  changes.  This  treatment  should  never  be  postponed 
until  the  paralysis  has  been  aggravated  by  overdistention,  but  should 
be  resorted  to  either  before  or  upon  the  first  appearance  of  intes- 
tinal distention.  Uniform  compression  of  the  abdomen  with  strips  of 
adhesive  plaster  and  bandage  applied  over  the  antiseptic  absorbent 


TREATMENT.  98 1 

dressing  immediately  after  the  operation  sliould  be  kept  up  until  all 
danger  from  the  occurrence  of  tympanites  has  passed.  When  the  dis- 
tention has  become  so  great  as  to  threaten  life,  the  treatment  should 
consist  of  the  employment  of  such  prompt  mechanical  measures  as 
will  diminish  the  intra-abdominal  pressure.  As  the  stomach  may 
also  be  dilated,  its  contents  should  be  removed  through  a  flexible 
stomach-tube,  followed  by  an  irrigation  with  a  harmless  antiseptic  solu- 
tion. Tubage  of  the  colon,  followed  by  a  turpentine  enema,  is  used 
for  the  same  purpose.  If  these  measures  fail  in  relieving  the  disten- 
tion, a  prompt  resort  to  intestinal  puncture  with  a  fine  hollow  needle 
becomes  imperative.  This  surgical  resource  may  be  repeated  as 
often  as  it  may  become  necessary  to  avert  danger  from  an  increasing 
intra-abdominal  pressure. 

Klotz  met  with  31  cases  of  intestinal  obstruction  in  569  abdom- 
inal sections  for  different  indications  ;  5  of  these  died.  This  com- 
plication was  observed  most  frequently  after  prolonged  operations 
and  tedious  dressings  and  when  antiseptics  were  used  in  the 
abdominal  cavity.  Since  1889,  when  this  latter  practice  was  set 
aside,  only  five  cases  of  obstruction  had  occurred.  On  that  account 
Klotz  was  not  inclined  to  look  on  ileus  as  a  septic  affection.  At 
necropsies  or  in  secondary  abdominal  sections  undertaken  to  relieve 
the  obstruction,  he  always  found  coils  of  small  intestine  immobilized 
by  great  coagula.  As  to  diagnosis,  nausea  on  the  second  day  was 
suspicious,  while  vomiting  on  the  third,  with  no  passage  of  flatus, 
undoubtedly  denoted  obstruction  of  the  intestines.  The  way  to 
prevent  ileus  was  to  avoid  antiseptics  and  toilet  of  the  peritoneum, 
to  check  completely  all  hemorrhage  from  wounded  surfaces,  and  to 
regulate  peri.stalsis  of  the  uninjured  intestine  as  soon  as  possible. 
This  was  accomplished  by  Seidlitz  powders  and  enemata  on  the 
second  day  after  operation.  When  occlusion  had  set  in,  Klotz 
washed  out  the  stomach  under  high  pressure,  and  inflated  the 
rectum  with  air.  The  latter  practice  was  highly  recommended. 
When  these  means  failed,  he  washed  out  the  stomach  once  more, 
and  after  complete  emptx'ing  of  that  organ  he  administered  large 
do.ses  of  castor  oil — up  to  fifty  grams  (over  an  ounce  and  a  half). 
In  all  cases  where  the  oil  was  given  it  was  retained  without  vomit- 
ing, and  the  intestine  was  freed  from  its  adhesions.  In  this  way 
secondary  abdominal  section  was  avoided.  Klutz  did  in>t  believe 
that  the.se  cases  were  septic  ;  there  was  little  or  no  ri.se  of  tempera- 
ture, and  this  was  rare  in  .sep.sis;  nor  was  the  obstruction  cau.sed  by 
bands  of  fibrin.  The  intestine  was  always  found  embedded  in  a 
clot  and  fixed  to  it.  almost  always  at  a  point  where  the  .serous  coat 
had  been  wounded. 

The  views  concerning  the  proper  treatment  of  such  ca.ses  depend 
entirely  on  the  opinions  held  regarding  the  cau.se  of  obstruction. 
Some  operators  favor  reopening  of  the  abdominal  cavity,  .searching 
for  and  removing  the  mechanical  cause  of  tiie  (obstruction  ;  others, 
who  take  the  ground  that  the  obstruction  is  usually  due  to  intestinal 


982         INTESTINAL    OBSTRUCTION    AFTER    ABDOMINAL    SECTION. 

paralysis,  are  in  favor  of  a  plan  of  treatment  calculated  to  restore 
the  temporarily  suspended  intestinal  function.  In  the  latter  class 
of  surgeons  belongs  Stumpf,  of  Munich,  who  has  had  occasion  to 
observe  two  cases  of  paralytic  ileus  after  laparotomy,  and,  inasmuch 
as  this  is  one  of  the  most  formidable  and  dangerous  complications 
that  may  supervene  after  laparotomy,  he  describes  the  treatment 
that  he  employed.  It  is  an  extremely  interesting  fact  that,  in  one 
of  the  cases  referred  to,  the  symptoms  of  ileus  made  their  appear- 
ance immediately  after  the  intervention.  The  patient  had  barely 
been  taken  back  to  bed  when  feculent  vomiting  set  in,  which  on 
the  following  day  increased  in  frequency  until  it  recurred  every  five 
or  ten  minutes.  He  vainly  resorted  to  all  the  measures  usually 
employed  under  such  circumstances,  and  ultimately  despairing  of 
the  case,  contented  himself  with  feeding  the  patient  by  nutrient 
enemata,  which,  curiously  enough,  were  largely  retained  without 
great  difficulty.  From  the  sixth  to  the  eighth  day  the  grave 
symptoms  gradually  improved,  and  the  patient  was  soon  out  of 
danger.  He  is,  therefore,  of  the  opinion  that,  in  cases  of  paralytic 
ileus,  it  is  useless  to  again  open  the  abdomen,  and  that  copious 
rectal  injections,  nutrient  enemata,  and  medical  treatment  will  prove 
more  beneficial  than  operation.  It  is  absolutely  certain  that  the 
employment  of  asepsis,  especially  by  dry  means,  materially  reduces 
the  number  of  cases  of  intestinal  obstruction. 

Among  the  most  important  prophylactic  precautions  against  this 
grave  postoperation  complication  must  be  enumerated  : 

Quick,  but  not  hasty,  operating  ;  withholding  of  irritating  anti- 
septics from  the  abdominal  cavity;  gentle  and  as  little  handling  of 
the  abdominal  contents  as  possible  ;  careful  hemostasis  ;  covering 
of  raw  surfaces  with  peritoneum  wherever  this  can  be  done  ;  and  an 
early  resort  to  cathartics  and  high  enemata  to  maintain  or  restore 
intestinal  peristalsis. 


CHAPTER  XXVI. 

STRANGULATED  HERNIA. 

One  of  the  most  dangerous  accidents  that  the  general  practitioner 
is  often  called  upon  to  treat  is  strangulated  hernia.  An  early  diagno- 
sis and  prompt  action  are  necessary  in  such  cases  to  prevent  gangrene 
of  the  strangulated  intestinal  loop,  and  death  from  exhaustion  or 
septic  complications.  If  a  hernia  that  has  become  .strangulated 
contains,  as  it  usually  does,  a  knuckle  of  any  part  of  the  intestinal 
tract,  the  accident  is  announced  and  is  clinically  characterized  by  a 
complexus  of  symptoms  analogous  to,  or  at  any  rate  closely  resem- 
bling, what  is  observed  in  cases  of  intestinal  obstruction  from  other 
mechanical  causes.  The  symptoms  are  modified  by  the  part  of  the 
intestinal  canal  involved  in  the  strangulation  and  the  degree  of 
constriction. 

An  irreducible  hernia  attended  by  symptoms  of  incomplete  ob- 
struction is  called  an  incarcerated  hernia.  The  constriction  in  such 
cases  is  sufficient  to  impede  the  passage  of  intestinal  contents  with- 
out endangering  the  circulation  in  the  incarcerated  loop.  In  the 
acute  form  of  strangulation  complete  arrest  of  the  circulation  and 
gangrene  of  the  strangulated  loop  may  take  place  in  less  than 
twenty-four  hours.  In  the  former  case  the  obstruction  is  par- 
tial ;  in  the  latter,  always  complete.  Any  hernia  may  become 
strangulated  regardless  of  its  location  and  size.  Strangulated 
hernia  is  met  with  most  frequently  in  the  anatomic  localities  most 
predisposed  to  hernia  formation.  Inguinal  hernia  constitutes  84  per 
cent,  of  all  herniae,  femoral  10  per  cent.,  and  umbilical  5  per  cent. 
.Strangulated  hernia,  therefore,  occurs  most  frequently  in  inguinal, 
femoral,  and  umbilical  herniae,  while  a  strangulated  diaphragmatic, 
obturator,  properitoneal,  etc.,  hernia  is  a  surgical  rarity,  owing  to 
the  infrequency  with  which  the  latter  anatomic  forms  of  hernia 
occur.  Umbilical  and  femoral  herniae  are.  on  the  whole,  more  liable 
to  .strangulation  than  inguinal  hernia.  Ventral  hernia  following  as 
a  remote  complication  of  laparotomy  or  injury  of  the  abdominal 
wall  -seldom  becomes  strangulated,  owing  to  the  yielding  nature  o( 
the  tissues  that  surround  the  hernial  sac.  The  small  ventral  herni.e 
found  so  often  in  the  median  line,  or  a  littk;  to  one  side  of  it, 
between  the  ensiform  cartilage  and  umbihcus.  as  a  rule  contain  only 
omentum,  which  is  .seld(^m  found  strangulated,  but  almo.st  always 
adherent  to  the  internal  surface  of  the  minute  hernial  sac.  'Ihe.sc 
herniae  are  often  a  source  of  pain  and  ga.stric  and  intestinal  disturb- 
ance, but  seldom  give  ri.se  to  complete  obstruction  and  other  .symp- 
toms that  accompany  strangulation  of  an  intestinal  loop. 

Etiology.— A  hernia  is  strangulated  when,  from  any  cau.se,  tlie 

9«3 


984  STRANGULATED    HERNIA. 

intestinal  loop  in  the  hernial  sac  has  become  impermeable,  usually 
by  constriction  at  its  neck,  so  that  reduction  is  difficult  or  impossi- 
ble, the  constriction  at  the  same  time  producing  symptoms  of 
obstruction  and  endangering  the  circulation  in  the  protruded  bowel. 
The  immediate  cause  of  the  strangulation  is  not,  as  was  formerly 
supposed,  a  contraction  of  the  lierjiial  ring,  but  a  sudden  increase  in 
the  hernial  co?itents.  The  hernial  ring  remains  passive,  and  constric- 
tion takes  place  by  an  increase  in  volume  of  the  structures  that  are 
embraced  by  it.  The  more  unyielding  the  tissues  that  compose 
the  ring,  and  the  narrower  the  ring,  the  greater  is  the  danger  of 
strangulation  in  the  event  of  a  sudden  increase  in  the  volume  of 
hernial  contents.  It  is  for  this  reason  that  umbilical  and  femoral 
hernise  are  more  prone  to  strangulation  than  inguinal  and  ventral 
herniae,  the  umbilical  ring  and  Poupart's  ligament  furnishing 
greater  resistance  than  the  muscles  of  the  abdominal  wall.  It  is 
for  the  same  reason  that  a  small  hernia  becomes  more  frequently 
strangulated  than  a  large  one.  The  sudden  increase  of  hernial 
contents  occurs  either  in  consequence  of  exaggerated  intestinal 
peristalsis  or  because  of  the  influence  of  increased  intra-abdominal 
pressure.  In  the  first  instance  the  intestinal  contents  accumulate 
rapidly  in  the  knuckle  of  bowel  in  the  hernial  sac,  the  permeability 
of  which  is  always  impaired  more  or  less  by  the  existing  flexion. 
The  intestinal  loop,  unable  to  empty  the  contents  as  fast  as  forced 
into  it  by  the  strong  peristalsis,  becomes  distended,  finally  paretic, 
and  the  venous  engorgement  that  follows  as  a  natural  sequence 
becomes  the  direct  cause  of  the  subsequent  strangulation.  Stran- 
gulation in  such  cases  is  preceded  by  intestinal  disturbances  that 
lead  to  violent  peristalsis.  These  are  the  cases  in  which  reduction 
of  the  hernia  by  taxis  is  greatly  facilitated  by  the  administration  of 
a  sedative  dose  of  an  opiate. 

More  frequently  strangulation  is  caused  by  a  sudden  increase  in 
volume  of  the  contents  of  the  hernial  sac,  as  the  direct  mechanical 
result  of  abnormal  intra-abdominal  pressure.  Laughing,  coughing, 
vomiting,  straining,  lifting,  a  fall  upon  the  feet,  a  misstep,  are  the 
most  frequent  causes  mentioned  by  patients  as  the  direct  cause  of 
the  strangulation.  Under  such  conditions  the  strangulation  is  pro- 
duced by  the  descent  of  more  of  the  intestines,  thus  increasing  the 
length  and  volume  of  the  intestinal  loop  in  the  hernial  sac  ;  or  by 
the  descent  of  a  second  knuckle  of  the  bowel ;  or  the  intestinal  loop 
is  compressed  by  the  descent  of  the  omentum  already  in  the  sac ; 
or  the  omentum  is  suddenly  forced  into  the  sac  in  addition  to  its 
former  contents.  The  partial  strangulation  incident  to  the  sudden 
increase  in  the  volume  of  hernial  contents  soon  becomes  complete 
by  the  venous  engorgement,  which  follows  the  partial  strangulation 
as  a  necessary  result.  The  next  link  in  the  chain  of  mechanical  con- 
ditions that  aggravate  the  strangulation  is  edema  of  the  parts  below 
the  constriction.  This  eventually  becomes  the  direct  cause  of  com- 
plete venous  stasis  and  gangrene. 


SYMPTOMS    AND    DIAGNOSIS.  985 

Gangrene  of  the  strangulated  intestine  is  not  the  result  of  an  in- 
adequate supply  of  arterial  blood,  but  is  produced  by  arrest  of  the  venous 
circulation  by  compression  or  thrombosis.  The  arterial  circulation  is 
finalh'  suspended  in  consequence  of  complete  venous  stasis.  Gan- 
grene of  the  strangulated  intestine  is  produced  by  mechanical 
conditions  at  the  seat  of  constriction,  which  first  embarrass  and 
later  completely  arrest  the  venous  circulation.  Besides  the  open- 
ing through  which  the  hernia  has  descended,  the  most  frequent 
seat  of  the  strangulation  in  all  anatomic  forms  of  hernia,  constric- 
tion may  take  place  in  the  neck  of  the  hernial  sac,  in  the  sac  itself 
by  bands  of  adhesion,  and,  finally,  by  a  twist  of  the  intestinal  loop 
in  the  sac. 

The  pathologic  conditions  produced  by  the  strangulation  vary 
according  to  the  location  and  degree  of  constriction  and  the  pres- 
ence or  absence  of  infection.  If  the  constriction  only  impedes,  but 
does  not  arrest,  the  venous  circulation,  transudation  from  the  en- 
gorged capillaries  takes  place  and  the  hernia  becomes  complicated 
by  an  acute  hydrocele  of  the  tunica  vaginalis.  Localized  gangrene 
under  the  constricting  band  occurs  if  the  pressure  afiects  only  a 
limited  portion  of  the  circumference  of  the  bowel  to  the  extent  of 
causing  pressure  necrosis.  Under  such  circumstances  the  necrosis 
is  linear  and  corresponds  in  direction  and  width  to  the  constricting 
band.  If  the  constriction  is  more  uniform,  venous  circulation  is 
first  embarrassed,  later  completely  interrupted,  and  unless  timely 
operative  treatment  is  resorted  to,  gangrene  of  the  whole  loop  below 
the  point  of  constriction  follows  as  an  inevitable  sequence. 

An  intestine  that  has  been  strangulated  for  some  time  under- 
goes textural  changes  that  render  its  wall  permeable  to  the  passage 
of  pathogenic  microbes  before  gangrene  and  perforation  open  up  a 
free  passageway  for  the  escape  of  intestinal  contents  into  the  hernial 
sac.  Bacteriologic  experiments  made  with  the  fluid  in  the  hernial 
sac  in  cases  in  which  no  perforation  or  gangrene  was  fount!  at  the 
time  the  operation  was  performed  have  demonstrated  in  many 
instances  the  presence  of  pathogenic  microbes  that  could  have  found 
their  way  into  the  sac  only  through  the  intestinal  wall  damaged  by 
the  passive  venous  hyperemia.  If  pyogenic  bacteria  find  entrance 
through  the  permeable  intestinal  wall  into  the  sac  in  sufficient  (juan- 
tity  and  \'irulenceto  induce  suppuration,  al)sccss  formation  may  take 
place  independently  of  gangrene  and  perforation.  Acute  sujjpur- 
ative  inflammation  of  the  hernial  sac  without  gangrene  is,  however, 
a  very  rare  complication  of  .strangulated  hernia.  Acute  inflamma- 
tion of  the  sac,  phlegmonous  inflammation  of  the  connective  tissue 
outside  of  the  .sac,  and  emphysema  are  conditions  that  almost  unerr- 
ingly announce  the  occurrence  of  gangrene  of  the  strangulated 
intestine. 

Symptoms  and  Diagnosis. — In  rare  ca.ses  an  acute  .strangula- 
tion is  initiated  by  symptoms  that  denote  shock.  The  patient 
faints,  the  pulse  is  rapid  and  with<jut  force,  the  surface  of  the  skin 


986  STRANGULATED    HERNIA. 

is  cold  and  covered  with  a  cold,  clammy  perspiration,  and  the  pupils 
are  dilated.  These  are  the  cases  in  which  the  constriction  is  tight 
from  almost  the  very  beginning  of  the  accident,  the  shock  being  a 
reflex  manifestation  of  the  sudden  compression  and  irritation  of  the 
sympathetic  nerves.  With  the  reaction  the  local  symptoms  develop 
in  rapid  succession  and  point  to  the  existence  of  complete  intesti- 
nal obstruction.  Ordinarily  the  patient  experiences  a  sudden  pain 
in  the  hernial  swelling,  which  at  the  same  time  becomes  tender  to 
the  touch.  If  the  patient  is  aware  of  the  existence  of  the  hernia, 
he  suspects  what  has  happened  and  makes  attempts  to  reduce  it. 
In  doing  so  he  discovers  that  the  swelling  is  larger  and  much  harder 
than  usual  and  more  painful  on  manipulation.  In  some  instances 
the  local  symptoms  are  slight  or  almost  entirely  wanting,  and  if  the 
patient  is  ignorant  of  the  existence  of  a  hernia,  he  usually  resorts 
to  treatment  directed  toward  a  disturbance  or  derangement  of  the 
intestinal  canal  from  other  causes.  The  constipation  is  absolute. 
The  bowel  movements  following  enemata  are  limited  to  the  evacu- 
ation of  intestinal  contents  below  the  seat  of  obstruction.  Vomit- 
ing is  a  constant  and  distressing  symptom,  and  is  always  aggravated 
by  the  administration  of  cathartics  that  are  usually  resorted  to  before 
medical  aid  is  summoned.  TJie  paroxysmal  abdominal  pain  caused 
by  the  violent  peristalsis  is  referred  to  the  umbilical  region.  As  the 
obstruction  is  generally  complete,  the  strangulated  loop  is  imper- 
meable to  gas  ;  consequently  tympanites  soon  sets  in  and  adds  to 
the  abdominal  distress.  At  first  the  vomit  consists  of  stomach- 
contents,  followed  later  by  intestinal  contents,  which,  if  the  obstruc- 
tion is  low  down  in  the  intestinal  canal,  soon  become  distinctly 
fecal. 

In  all  cases  of  intestinal  obstruction  it  becomes  the  imperative 
duty  of  the  attending  physician  to  examine  carefully  all  the  hernial 
regions  for  the  existence  of  a  strangulated  hernia.  The  patient's 
statement  that  he  is  not  the  subject  of  hernia  can  not  be  relied  upon 
to  exclude  this  cause  of  intestinal  obstruction.  If  the  patient  is 
obese  and  the  hernia  small,  it  requires  the  most  painstaking  exam- 
ination to  detect  the  hernial  swelling.  This  is  particularly  true  of 
small  femoral  hernise  in  obese  women.  If  the  hernial  swelling  is 
found,  palpation  will  show  that  it  is  very  tense,  painful  to  the  touch, 
and  lacks  impulse  on  coughing.  Under  moderate  pressure  the 
swelling  is  not  reduced  in  size.  If  the  strangulated  loop  is  distended 
with  gas,  percussion  reveals  a  tympanitic  area  that  in  size  corre- 
sponds to  the  strangulated  loop.  If  the  swelling  is  large  and  the 
coverings  of  the  sac' are  thin,  careful  manipulation  of  the  contents 
of  the  sac  may  give  definite  information  as  to  the  character  of  its 
contents.  A  large  mass  of  omentum  in  front  of  the  knuckle  of 
bowel  can  usually  be  identified  by  this  method  of  examination,  or, 
in  the  absence  of  the  omentum,  the  strangulated  loop  can  be 
traced  through  the  intact  skin  in  the  same  manner.  Edema  and 
redness  of  the  skin  over  the  sac  are  indications  that  eanerene  has 


SYMPTOMS    AND    DIAGNOSIS.  gg? 

occurred,  and  the  existence  of  a  subcutaneous  emphysema  or  a 
general  peritonitis  is  unmistakable  evidence  that  the  strano-ulation 
has  resulted  in  gangrene.  The  existence  of  a  hard,  tender  hernial 
swelling  in  cases  of  acute  intestinal  obstruction  is  a  reliable,  if  not 
an  infallible,  indication  that  the  obstruction  has  been  caused  by 
strangulation  of  the  hernia. 

The  differential  diagnosis  must  next  be  considered  between 
strangulated  hernia  and  other  causes  of  intestinal  obstruction,  and 
also  the  following  affections  : 

Incarcerated  hernia,  inflamed  hernia,  cryptorchism,  lymphaden- 


Fig.  532. — I^rge  incarcerated  .scrotal  lieruia.      Operation  -ucccb.-iful  (."^i.    !<■  i])h'.s 
Hospital,  Chicago). 

itis,  hematocele  of  the  tunica  vaginalis,  and  suppurative  vaginalitis. 
In  making  a  differential  diagnosis  between  strangulated  licrnia  and 
allied  affections  that  may  simulate  it,  it  must  be  remembered  that 
the  most  striking  clinical  feature  of  the  former  consists  in  a  com- 
plexus  of  .symptoms  that  points  to  the  existence  of  intestinal  obstruc- 
tion. Intestinal  obstruction  from  internal  causes  could  give  ri.se  to 
confusion  only  by  the  coexi.stence  of  an  irreducible,  incarcerated,  or 
inflamerl  hernia.  The  rarity  with  which  such  ca.ses  occur  in  |)rac- 
tice  would  justify  herniotomy  as  a  diagnostic  resource,  and  if  the 
hernia  can  be  excluded  as  the  cau.se  of  ..bstniction.  laparotomy  lor 


988  STRANGULATED    HERNIA. 

the  relief  of  the  internal  obstruction  should  be  resorted  to  without 
delay.  The  patient  and  friends  should  be  informed  of  the  intent 
of  the  first  operation,  and  the  necessary  preparations  made  for  the 
second. 

Incarcerated  and  inflamed  herniae  do  not  give  rise  to  intestinal 
obstruction,  and  the  symptoms  are  referred  to  the  hernial  swelling 
exclusively. 

Torsion  and  strangulation  of  an  undescended  testicle  in  the 
inguinal  canal  may  produce  reflex  vomiting  and  other  symptoms 
that  might  lead  to  the  suspicion  of  the  existence  of  intestinal 
obstruction,  and  the  hard  swelling  might  suggest  a  small  strangu- 
lated hernia.  The  absence  of  the  testicle  from  the  scrotum  and  the 
sickening  pain  caused  by  pressure  over  the  swelling  would  at  once 
call  the  attention  of  the  physician  to  cryptorchism. 

Suppurative  vaginalitis,  either  as  a  primary  affection  or  follow- 
ing in  the  course  of  a  suppurative  orchitis  or  epididymitis,  is 
attended  by  fever  and  the  local  signs  of  an  acute  inflammation. 
Should  gastro-intestinal  disturbances  obscure  the  case,  an  explora- 
tory puncture  will  demonstrate  the  nature  of  the  swelling.  The 
same  diagnostic  resource  can  be  relied  upon  in  making  a  positive 
diagnosis  of  hematocele. 

Lymphadenitis  in  localities  the  favorite  sites  of  hernia  has  re- 
peatedly been  mistaken  for  strangulated  hernia  and  vice  versa.  The 
differential  diagnosis  between  a  suppurative  lymphadenitis  in  the 
groin  and  strangulated  hernia  is  sometimes  very  difficult.  If  the 
inflammatory  affection  of  the  glands  is  multiple,  a  correct  diagnosis 
can  be  made  by  establishing  this  fact,  and,  should  any  doubt  remain, 
by  locating  the  source  of  infection.  If  the  inflammatory  swelling  is 
single  and  occupies  the  site  of  a  femoral  hernia,  caution  is  necessary 
in  resorting  to  the  use  of  the  knife.  The  possibility  of  the  swelling 
being  an  inflamed  or  strangulated  hernia  must  be  borne  in  mind  in 
making  the  incision,  which  in  doubtful  cases  should  be  made  by 
careful  dissection  in  the  same  manner  as  in  the  operation  for  strangu- 
lated hernia. 

Prognosis. — Under  aseptic  precautions  herniotomy  is  so  safe  an 
operation  that  the  mortality  of  strangulated  hernia  has  been  reduced 
to  a  minimum.  The  prognosis,  therefore,  is  very  favorable,  pro- 
vided a  correct  diagnosis  is  made  and  the  strangulation  relieved  by 
taxis  or  operation  before  the  intestinal  loop  has  been  damaged  to 
any  considerable  extent.  An  early  diagnosis  and  timely  and  judici- 
ons  interference  by  taxis  or  operation  are  necessary  in  prei'enting  the 
complications  that,  in  the  past,  have  maintained  the  high  mortality  of 
strangidated  hernia.  The  prognosis  depends  entirely  on  the  con- 
dition of  the  hernial  contents,  and  this  is  determined  largely  by 
the  time  that  has  intervened  between  the  occurrence  of  the  accident 
and  the  resort  to  taxis  or  operative  interference.  The  length  of 
time  the  strangulation  has  existed  has  a  direct  bearing  on  the  mor- 
tality that  follows  the  subsequent  efforts  to  relieve  the  strangulation. 


TREATMENT. 


989 


But  there  are  many  exceptions  to  this  rule.  If  the  constriction  is 
tight  ahnost  from  the  very  beginning,  gangrene  of  the  strangulated 
intestinal  loop  may  occur  in  the  course  of  a  very  few  hours,  while 
under  more  favorable  local  conditions  the  bowel  may  be  found  viable, 
even  when  the  operation  for  its  relief  has  not  been  performed  until 
several  days  after  the  accident  has  occurred.  The  danger  from 
gangrene  in  a  given  space  of  time,  all  other  things  being  equal,  is 
greatest  it  the  constricting  band  is  narrow  and  unyielding,  and  if 
pressure  is  exerted  directly  upon  the  intestine.  A  small  femoral 
hernia  with  little  or  no  omentum  in  the  sac  is  the  one  in  which,  as 
a  rule,  the  circulation  in  the  strangulated  intestine  is  completely 
arrested  in  the  shortest  space  of  time.  On  the  contrary,  if  the  hernia 
is  large,  and  more  especially  if  a  large  elastic  cushion  of  omentum 
is  interposed  between  the  constricting  band  and  the  intestine,  gan- 
grene, if  it  takes  place,  occurs  as  a  more  remote  complication. 

Much  valuable  prognostic  information  can  be  obtained  from  a 
careful  study  of  the  clinical  history.  If  the  symptoms  of  obstruc- 
tion are  acute,  and  the  hernial  swelling  is  very  hard,  and  if  tender- 
ness and  local  pain  are  early  and  prominent  symptoms,  the  proba- 
bility of  the  early  occurrence  of  gangrene  is  always  great.  If,  on 
the  other  hand,  the  local  symptoms  are  ill  defined,  vomiting  and 
tympanites  set  in  slowly,  and  the  hernial  swelling  lacks  hardness, 
the  prognosis  is  correspondingly  more  favorable.  Discoloration  of 
the  skin  over  the  hernia  and  edema  suggest  gangrene,  and  this 
condition  of  the  bowel  can  be  safely  predicted  in  the  presence  of 
emphysema.  A  more  distant  indication  of  the  existence  of  the 
same  condition  of  the  strangulated  bowel  is  a  tendency  to  general 
capillary  stasis. 

Treatment. — The  treatment  of  a  strangulated  hernia  consists 
in  effecting  reduction  as  soon  as  possible  after  the  strangulation  has 
occurred,  and  if  this  fail,  or  if  the  condition  of  the  hernial  contents 
does  n(jt  permit  of  such  an  attem{)t,  in  relieving  the  constriction  by 
operative  treatment  and  then  dealing  with  the  strangulated  loop  as 
indicated  by  its  condition. 

The  medical  treatment  in  such  cases  is  of  little  avail.  No  modern 
physician  would  for  a  moment  consider  seriously  the  therapeutic 
value  of  nauseating  enemata  or  the  internal  use  of  relaxing  anti- 
spasmodic remedies,  so  much  relied  upon  in  facilitating  taxis  before 
herniotomy  was  shorn  of  its  great  mortality  by  the  introduction  of 
ase[>tic  surgery.  No  time  shoidd  be  lost  in  vain  attempts  to  relieve 
the  strangulation  by  a  resort  to  drugs. 

In  a  recent  strangulation,  two  things  can  be  done  with  the  expec- 
tation of  favorably  influencing  the  acute  symptoms  and  of  tacilitating 
the  subsequent  taxis  :  (i)  The  administration  of  an  opiate  will  allay 
the  violent  peri.stalsis  above  the  seat  of  obstruction,  and,  by  doing 
.so,  will  control,  to  a  certain  extent  at  lea.st,  one  of  the  cau.ses  tli;.t 
lead  to  speedy  arrest  of  the  circulatif)n  in  the  strangulated  loop  and 
to  gangrene.      (2)   A  high  enema,  properly  admin istired,  will  stim- 


990 


STRANGULATED    HERNIA. 


ulate  peristalsis  in  the  intestine  below  the  seat  of  obstruction,  and 
at  the  same  time  will  clear  that  portion  of  the  bowel  of  its  contents, 
thereby  increasing  intra-abdominal  space,  creating  conditions  favor- 
able to  subsequent  attempts  at  reduction  of  the  hernia  by  taxis. 

Taxis. — In  the  treatment  of  a  recently  strangulated  hernia  no 
time  should  be  lost  in  effecting  reduction  by  taxis.  By  the  term 
taxis  here  is  meant  the  reduction  of  a  hernia  by  methodic  manipu- 
lation without  instruments.  Taxis  is  indicated  in  all  cases  in  which, 
from  the  time  that  intervened  between  the  occurrence  of  the  acci- 
dent and  the  attempt  made  at  reduction,  gangrene  would  not  be 
expected  to  take  place,  and  in  cases  in  which  the  general  and  local 
symptoms  would  suggest  a  similar  favorable  condition  of  the  stran- 
gulated bowel.  /;/  doubtful  cases  it  is  safer  to  resort  at  once  to 
herniotomy ,  rather  than  to  assume  the  risks  of  reducing  by  taxis  a  stran- 
gulated loop  that,  when  returned  into  the  abdominal  cavity,  might  be- 
come the  cause  of  a  septic  peritonitis. 

Taxis  is  performed  as  follows  :  The  patient  is  placed  in  the 
recumbent  dorsal  position,  with  the  pelvis  well  elevated  and  the 
thisrhs  and  le^s  flexed,  to  relax  the  abdominal  muscles  and  the  con- 
stricting  band  or  ring.  According  to  the  size  of  the  hernia,  com- 
pression is  made  with  the  finger-tips  or  the  whole  right  hand.  With 
the  thumb  and  index-finger  of  the  left  hand  compression  is  made 
of  the  intestinal  loop,  omentum,  or  both,  below  the  constricting 
ring,  in  such  a  way  as  to  empty  the  contents  of  the  strangulated 
loop  first.  If  the  hernia  is  not  reduced  after  a  short  attempt,  the 
hernial  swelling  is  grasped  firmly  with  the  right  hand,  when  trac- 
tion is  made,  combined  with  lateral  movements  ;  while  the  sac  and 
its  contents  are  on  the  stretch,  the  thumb  and  index-finger  of  the 
left  hand  are  again  employed  in  emptying  the  intestinal  contents 
by  compression,  kneading,  and  stroking  in  the  direction  of  the  her- 
nial canal.  In  reducing  an  umbilical  hernia,  the  pressure  is  directed 
toward  the  umbilical  ring  ;  in  inguinal  hernia,  in  the  direction  of  the 
inguinal  canal ;  in  femoral  hernia,  at  first  downward,  toward  the 
saphenous  opening,  and  later  in  the  direction  of  the  crural  canal. 
In  difficult  cases  Trendelenburg's  position  will  prove  useful  in  per- 
forming taxis.  The  manipulations  must  be  made  systematically 
and  without  interruption,  and  the  force  used  should  never  be  suffi- 
cient to  endanger  the  strangulated  loops,  the  walls  of  which,  even  if 
not  gangrenous,  may  have  suffered  sufficiently  from  the  effects  of 
the  strangulation  to  diminish  materially  their  resistance  to  pressure. 
Reckless  taxis  has  resulted  in  rupture  of  the  boivel,  and  such  an  acci- 
dent has  almost  always  been  follozved  by  deatli,  even  in  cases  in  wJiich 
herniotomy  zvas  afterward  performed.  Such  an  accident  should  never 
occur  in  the  practice  of  a  careful  physician,  and  if  reduction  under 
gentle  force  does  not  take  place,  the  failure  is  a  sufficient  indication 
for  the  immediate  performance  of  herniotomy. 

Reduction  is  often  facilitated  by  the  application  of  cold,  either 
in  the  form  of  an  ice-bag  or  ether  spray.     In  difficult  cases  general 


TAXIS. 


991 


anesthesia  is  always  required,  and  must  be  carried  to  the  extent  of 
complete  muscular  relaxation,  as  an  incomplete  anesthesia  will  be 
found  more  harmful  than  useful.  In  the  absence  of  contraindica- 
tions chloroform  deserves  the  preference  to  ether.  How  long  is  it 
safe  or  advisable  to  continue  taxis  ?  It  is  easier  to  answer  this 
question  now  than  it  was  twenty-five  years  ago.  No  harm  should 
ever  result  to  the  hernial  contents  from  taxis.  It  is  difficult  to  fix  the 
time  limit  witli  precision.  The  length  of  time  it  is  safe  to  continue 
the  manipulations  will  depend  largely  on  the  degree  of  strangula- 
tion, the  condition  of  the  hernial  contents,  and  especially  on  the 
amount  of  force  used  in  attempting  the  reduction.  The  experienced 
physician  will  be  able,  after  a  few  gentle  efforts,  to  decide  whether 
or  not  it  is  advisable  to  prolong  the  taxis.  He  will  be  guided  in 
this  matter  by  the 
effects  of  the  pres- 
sure and  manipu- 
lations on  the  size 
and  consistence  of 
the  swelling.  If 
the  hernial  swell- 
ing is  reduced  in 
size  and  becomes 
softer,  it  would 
indicate  that  the 
contents  of  the  in- 
testinal loop  have 
been  reduced  and 
that  successful  re- 
duction of  the 
hernia  will  follow 
by  a  continuance 
of  the  manipula- 
tions. If  the  size 
and  hardness  of 
the  hernia  are  not 
diminished  after  a 


I-'ig-  533- 


-Reductiun   of  femoral   liL-niia,  strangulation    re- 
maining (after  Marcy). 


ith    th( 


gentle  trial  for  ten  or  fifteen  minutes  wit 
patient  fully  under  the  influence  of  an  anesthetic,  it  is  a  waste  of 
time  and  detrimental  to  the  patient  tf)  persi.st  in  the  efforts,  and 
herniotomy  should  be  performed  without  delay.  The  patient  should 
be  informed  beforehand  that,  in  case  taxis  fails,  herniotomy  will  be 
performed  during  the  same  narcosis  ;  the  necessary  pre])arations 
should  be  made  for  the  operation.  After  successful  taxis,  rest  in 
bed  and  an  absolute  diet  should  be  enforced  for  at  iea.st  twenty-four 
hours,  and  before  the  patient  leaves  his  bed  he  must  be  supplied 
with  a  well-fitting  truss. 

If  the  symi)toms  of  ob.struction  are  nf)t  relieved  by  the  rctliicti(Mi, 
one  of  th(.-  fr)lIowing  cau.ses  must  be  suspected  :  Ketm-n  of  injured  or 
gangrerujus  bowel,  peritonitis,  reduction  of  hernia  en  masse,  a  .second 


STRANGULATED    HERNIA. 


Strangulated  hernia.  If  a  second  strangulated  hernia  can  not  be 
found,  laparotomy  is  the  only  recourse  for  the  detection  and  treat- 
ment of  the  remaining  cause  or  causes  of  the  persistent  obstruction. 
Herniotomy. — Herniotomy  is  the  operation  resorted  to  for  the 
rehef  of  a  strangulated  hernia  by  cutting  the  constriction.  As  the  sac 
of  a  hernia  is  a  part  of  the  parietal, peritoneum,  and  as  the  modern 
operation  almost  always  includes  opening  of  the  sac,  it  invariably 
implicates  the  peritoneal  cavity.  The  operation  is  a  laparotomy,  and 
should,  from  a  practical  standpoint,  be  regarded  as  such.  It  con- 
sists in  opening  a  protruding  pouch  of  the  parietal  peritoneum,  and 
deals  with  one  or  more  of  the  abdominal  organs  more  or  less  dam- 
aged by  the  constriction.      The  same  pedantic  preparations  must  be 

observed  and  carried 
into  effect  to  guard 
against  peritoneal  in- 
fection as  in  perform- 
ing a  laparotomy 
through  the  intact 
abdominal  wall  for 
other  indications.  The 
hernial  regions  are 
hard  to  disinfect ; 
consequently  special 
care  is  necessary  to 
prepare  the  field  of 
operation  with  the 
requisite  degree  of 
thoroughness. 

Herniotomy  is  in- 
dicated when  taxis 
fails  and  when  gan- 
grene of  the  strangu- 
lated loop  is  sus- 
pected. The  facility 
with  which  the  oper- 
ation can  be  performed  and  the  different  important  structures 
identified  depends  much  on  the  size  and  shape  of  the  external  in- 
cision. The  external  incision  must  be  ample,  and  of  such  shape 
as  to  expose  the  coverings  and  the  sac  freely  ;  it  must  be  made  as  far 
away  from  the  external  genitals  as  possible.  Curved  incisions  afford 
more  space  than  straight  incisions.  For  nearly  five  years  I  have 
made  curved  instead  of  straight  incisions  in  the  operations  for  the 
radical  cure  of  both  inguinal  and  femoral  herniae,  and  as  the  result 
of  quite  an  extensive  experience,  I  recommend  similar  incisions  for 
the  operative  relief  of  strangulated  hernia.  For  exposing  the  in- 
guinal canal,  the  incision  is  commenced  over  Poupart's  ligament,  at 
a  point  half-way  between  the  anterior  superior  spinous  process  of 
the  ilium  and  the  spine  of  the  pubes,  and  is  carried  obliquely  upward 


Fig-  534- — Curved  incision,  exposing  the  inguinal 
canal:  p,  Poupart's  ligament;  a,  a,  aponeurosis  of  ex- 
ternal oblique  reflected  ;  c,  conjoined  tendon  ;  h,  hernial 
protrusion  ;  s,  spermatic  cord. 


993 
In  a  <jentle 


HERNIOTOMY. 

and  inward  on  a  level  with  the  internal  in^-uinal  rincr 
curve  it  is  then  con-  *'" 

tinued  to  the  inner 
side  of  the  inguinal 
canal,  and  finally  is 
terminated  over  the 
spine  of  the  pubes. 
The  skin  and  super- 
ficial fascia  included 
by  the  horseshoe- 
shaped  incision  are 
then  reflected  in  the 
form  of  a  flap  as  far 
as  Poupart's  liga- 
ment, exposing  the 
pillars  of  the  ingui- 
nal canal  freely  to 
sight  and  touch.  In 
the  operations  for 
femoral  hernia  the 
beginning  and  ter- 
minal points  of  the 
incision  are  the 
same,  but  the  curve 
is  directed  down- 
ward  and   the   incision   is   extended   to   the    lower  border   of  the 

saphenous  opening. 

By    making    the    incisions    as    de- 
scribed, the  most  important  part  of  the 
field    of  operation    is    expt).scd    freely 
without  the  use  of  retractors ;  the  line 
of  incision  is  as  remote  from  the  exter- 
nal genitals  as  possible,  and  the  deep 
sutures    relied    upon     in     closing     the 
hernial   canal   are    covered   by  normal 
elastic  skin   instead   of  by  scar  tissue, 
as   is   the  case  if  a  .straight  incision  is 
made    directly    over    the     inguinal    or 
crural  canal.    Having  expo.scd  the  her- 
nial region  by  reflection  of  the  cutane- 
ous  flap,  the   remaining   layers  of  the 
hernia    are    picked    up    one    after    the 
other  between    two   dissecting   forceps, 
and  carefully  divided.      It  is  not  always 
easy  or  possible  to  distinguish  between 
the  different  layers,  but  as  long  as  the 
tissues  are  grasped  and  lifted  up  with 
dissecting  forceps,  carefully  identified  and  divided,  the  hernial  con- 
63 


Fig-  535- — Femoral  hernia  exposed  by  reflecting  oval 
flaps:  /./.,  Poupart's  ligament;  c.f.,  cribriform  fascia 
overlying  hernial  sac  ;  so,  saphenous  opening  ;  i.s,  internal 
saphenous  vein. 


Fig.  536. — Hernia  knives. 


994 


STRANGULATED    HERNIA. 


tents  are  safe.  The  dissecting  forceps  is  a  safer  and  more  useful 
instrument  than  the  grooved  director  in  making  the  deep  dissection 
and  in  exposing  the  hernial  sac.  The  most  important  layer  of  the 
hernial  covering  is  the  peritoneum.      When  this  has  been  reached, 


Fig.  537. — Tissue  forceps:  A,  Senn's  slide-catch  forceps  with  three  or  five  teeth; 
B,  E.  J.  Senn's  automatic  forceps;  C,  tissue  forceps  with  fine  teeth;  D,  mouse-tooth 
forceps  with  three  teeth. 


Fig.   538. — Grooved  directors:    A,    Kocher's;    B,   probe-pointed    director;   C,  ordinary 

grooved  director. 

it  is  incised  between  two  dissecting  forceps.  The  hernial  sac  should 
always  be  laid  open,  to  enable  the  surgeon  to  investigate  the  con- 
dition of  its  contents.  Division  of  the  constriction  outside  of  the 
sac  and  reduction  of  the  hernial   contents   without  inspection   are 


HERNIOTOMY. 


995 


procedures  that,  for  obvious  reasons,  have  become  obsolete  with 
the  adoption  of  aseptic  precautions  in  general  practice. 

The  next  step  in  the  operation  consists  in  relieving  the  constric- 
tion by  cutting  or  stretching  the  resisting  structures.  After  locating 
the  seat  of  constriction,  an  attempt  is  made  to  insert  the  tip  of  the 
index-finger  between  the  constricting  ring  and  the  hernial  contents, 
and  if  this  can  be  done,  the  opening  can  usually  be  enlarged  to  the 
requisite  extent  by  tearing  and  dilatation.  The  speedy  and  safe  re- 
moval of  the  constriction  requires,  as  a  preliminary  step,  the  laying 
open  of  the  hernial  sac  in  its  entire  length.  If  the  constriction  is 
tight,  a  grooved  or  Kocher's  director  is  carefully  inserted  between 
the  constricting  band  and  the  hernial  contents,  and,  by  gradual 
dilatation,  sufficient  room  can  usually  be  secured  for  the  insertion 
of  the  tip  of  the  left  index-finger,  which  is  then  utilized  as  a  guide 
for  the  probe-pointed  knife,  with  which  the  incision  or  incisions  are 
made  to  reliev^e  the  constriction.  The  palmar  surface  of  the  finger 
is  directed  toward  that  part  of  the  constricting  ring  where  the  knife 
is  to  be  used.  Adhesions  between  the 
sac  and  its   contents   underneath   the         --i-^^,  -- 

constrictmg  ring  are  separated  before 
inserting  the  hernia  knife.  If  the  ad- 
hesions are  too  firm  for  separation  by 
blunt  force,  necessitating  the  use  of 
the  knife,  it  is  advisable  to  leave  a 
thin  layer  of  the  sac  attached  to  the 
intestine  to  guard  against  accidental 
visceral  injuries.  The  hernia  knife  is 
inserted  with   the  flat  surface  resting  .   ^:'^-  539— Cutting  the  c<.n- 

^  r       1  stnctmg    ling    in    inguinal    lu'inia 

agamst    the    palmar    surface    ot    tiie       (von  Esmarch  and  Kowalzigi. 
finger    or  the   director,   if  the   finger 

can  not  be  used,  and  when  the  cutting-edge  has  passed  bc\'onti  the 
constricting  ring,  the  blade  is  turned  so  that  the  edge  is  directed 
toward  that  part  of  the  ring  where  the  incision  is  to  be  made.  The 
cutting  should  be  done  ratJicr  by  pressure  than  by  sato  motion,  in  order 
to  protect  the  blood-vessels  in  the  neighborhood  against  injury.  \\y 
making  pressure  against  the  back  of  the  knife  with  the  finger-tip  <>r 
director  the  ring  is  incised,  while  the  blood-ves.sels,  becoming  dis- 
placed, escape  the  cutting-edge  of  the  knife.  An  ordinary  straight 
or  curved  probe-pointed  bistoury  will  answer  the  pmpo.se  ol  a 
herniotome  of  special  construction  v(.r\'  well.  The  part  of  the 
blade  not  needed  for  the  cutting  can  be  rendered  harmless  by 
wrapping  a  strip  of  gauze  tightly  around  it.  Instead  of  making  one 
incision,  the  con.stricting  ring  can  be  nicked  in  several  places.  I  he 
place  of  incision  must  vary  according  to  the  location  of  the  hernia. 
In  external  inguinal  hernia  the  cut  is  made  in  an  outward  direction  ; 
in  internal  inguinal  hernia  it  is  made  in  an  inward  direction,  to  avoid 
wounding  the  epigastric  artery,  and  in  case  doubt  remains  as  to  the- 
exact  nature  of  the  hernia,  the  cut  is  made  in  an  upward  direction. 


996  STRANGULATED    HERNIA. 

In  femoral  hernia  Gimbernat's  ligament  is  incised,  and  as  the  obtu- 
rator artery  may  have  an  anomalous  origin  from  the  deep  epigastric, 
it  is  necessary  to  make  the  cut  exclusively  by  making  pressure 
against  the  back  of  the  knife,  so  that  the  movable  artery  can  retreat 
from  the  edge  of  the  knife.  Incision  in  an  outward  direction  would 
endanger  the  femoral  vessels — in  an  upward  direction,  the  epigastric 
and  spermatic  cord  or  ligamentum  rotundum,  and  in  a  downward 
direction,  the  saphenous  vein. 

After  relieving  the  stricture  the  contents  of  the  hernia  are  sub- 
jected to  a  careful  examination  to  determine  what  course  to  pursue. 
The  most  important  part  to  examine  is  the  strangulated  bowel,  as 
the  omentum,  if  present,  is  usually  removed  if  the  condition  of  the 
bowel  warrants  reduction  and  if  herniotomy  is  followed  by  an  oper- 
ation for  the  radical  cure  of  the  hernia,  as  is  now  usually  done 
under  such  circumstances.  The  positive  evidences  of  gangrene  of 
the  bowel  are  perforations,  gas  or  feces  in  the  sac,  and  an  ashy 
green  color  of  the  strangulated  loop.  The  strangulated  loop  must 
be  drawn  down  sufficiently  to  expose  freely  the  line  of  constriction, 
as  a  limited  linear  necrosis  may  be  found  here,  while  the  remainder 
of  the  loop  may  be  in  a  condition  to  justify  its  return  after  the 
necrosed  area  has  been  buried  by  a  row  of  seromuscular  sutures. 
If  much  doubt  remain  in  the  mind  of  the  operator  as  to  the  con- 
dition of  the  bowel,  it  becomes  necessary  to  make  a  systematic  and 
thorough  examination.  If  the  bowel  present  a  gray-greenish  or 
brown  color,  the  color  itself  would  be  a  proof  of  gangrene. 

The  vitality  of  the  bowel  is  tested  by  the  presence  or  absence 
of  peristalsis  and  the  state  of  the  circulation.  If  peristalsis  follow 
pinching  of  the  intestinal  wall,  it  is  a  valuable  diagnostic  sign, 
tending  to  prove  the  absence  of  gangrene.  More  reliable  informa- 
tion, however,  is  to  be  derived  from  a  careful  investigation  of  the 
state  of  the  circulation.  If  any  doubt  remain  as  to  the  vitality  of 
the  bowel  after  the  constriction  has  been  relieved,  the  exposed  parts 
should  be  douched  with  hot  saline  solution.  Under  this  very  sim- 
ple treatment  the  intense  capillary  and  venous  engorgement  is  often 
relieved  in  a  very  few  minutes,  as  indicated  by  the  change  in  color 
of  the  bowel.  A  deep  red  is  soon  transformed  into  a  bright  red, 
and  almost  black  into  red.  Such  a  rapid  restoration  of  the  circula- 
tion leaves  no  question  as  to  the  advisability  of  resorting  to  reduc- 
tion. If  no  change  is  observed  in  the  circulation,  superficial  needle 
punctures  will  demonstrate  whether  or  not  the  circulation  has  been 
completely  arrested.  If  the  vascular  stasis  is  complete,  little  or  no 
blood  will  escape  from  the  punctures  ;  if  partial,  free  venous  hemor- 
rhage will  follow  the  procedure.  The  presence  of  thrombosed 
mesenteric  veins  always  contraindicates  reduction.  If  the  surgeon 
can  not  justify  himself  that  it  is  safe  to  reduce  the  hernia,  and  yet 
there  are  no  positive  evidences  of  gangrene,  it  is  advisable,  after 
emptying  the  loop  of  its  contents,  to  secure  it  in  position  by  one 
suture  embracing  the  mesentery  and  one  margin  of  the  wound,  to 


HERNIOTOMY. 


997 


apply  a  compress  wrung  out  of  hot  Tliicrsch's  solution  or  physiolo^TJc 
solution  of  salt,  and  examine  the  loop  every  few  hours  for  evidences 
of  a  return  of  the  circulation,  and  in  such  an  event,  resort  to  sec- 
ondary reduction  of  the  hernia.  If  the  circulation  fail  to  return  in 
from  four  to  six  hours,  it  is  safe  to  assume  that  gangrene  has 
occurred,  when  the  case  is  treated  accordingly.  If  there  is  no  local 
linear  gangrene  from  decubitus  and  the  state  of  the  circulation  of 
the  strangulated  loop  is  satisfactory,  immediate  reduction  of  the 
hernia  is  indicated.  If  only  a  small  portion  of  omentum  is  in  the 
sac  and  is  free  from  adhesions,  it  is  returned  first.  If  the  omentum 
is  adherent  to  any  extent,  and  more  particularly  if  the  omental 
mass  is  large,  it  is  excised.  The  omentum  is  tied  in  small  sections 
with  fine  silk  ligatures  before  the  amputation  is  made.  The  stump 
should  be  lightly  iodoformized,  after  which  it  is  anchored  with  a 
catgut  suture  to  the  abdominal  wall  above  the  hernial  aperture,  as 
otherwise  the  stump  retracts,  and,  by  forming  adhesions  with  intes- 
tinal coils,  may  subsequently  become  a  cause  of  intestinal  obstruc- 
tion. I  have  seen  such  cases,  and  I  now  invariably  resort  to  this 
procedure  as  an  important  prophx'lactic  precaution.  The  intestinal 
loop  must  not  be  returned  nntil  it  has  been  emptied  of  its  contents,  thus 
demo7istrating  its  permeability. 

The  reduction  is  made  by  replacing  first  that  part  of  the  loop 
that  descended  last.  Before  any  attempt  at  reduction  is  made,  it 
must  be  determined  that  the  intestine  is  free  ;  if  this  is  not  the 
case,  existing  adhesions  must  be  separated.  If  the  patient's 
general  condition  justifies  prolongation  of  the  operation,  the  re- 
duction is  followed  by  an  operation  for  the  radical  cure  of  hernia 
by  one  of  the  methods  now  in  use.  If  the  strangulated  loop  is 
gangrenous,  an  entirely  different  course  must  be  pursued.  Such 
patients  are  usually  not  in  a  condition  for  successful  treatment  by 
resection  and  circular  suturing,  which  otherwise  would  appeal  as 
the  ideal  treatment.  Primary  intestinal  resection  for  this  indication 
has  been  attended  by  a  feaiful  mortality.  At  the  present  time  the 
surgeon  is  usually  content  in  performing  a  life-.saving  operation, 
reserving  the  restoration  of  the  continuity  of  the  intestinal  canal 
for  a  later  operation.  If  the  gangrene  is  linear  and  limited,  and 
the  vascular  condition  of  the  loop  is  satisfactory,  burying  the 
necrosed  area  with  a  row  of  Lembert  stitches,  with  sub.sequent 
reduction  of  the  hernia,  is  the  proper  cour.se  to  pursue.  Radical 
operation  for  the  cure  of  the  hernia  in  such  ca.ses  is  contraindi- 
cated.  With  a  mesenteric  suture  tiie  intestinal  loop  should  he 
anchored  above  the  hernial  opening  and  gauze  drainage  estab- 
lished, so  that  in  the  event  of  perforation  occurring,  the  worst 
that  could  f<;llow  would  be  a  temporary  intestinal  fi.stula.  If 
the  gangrene  involve  the  entire  loop,  the  following  course  is  to  be 
pursued  : 

The  intestinal  loop  mu.st  be  drawn  down  until  he:ilth>'  bowtl 
can  be  .seen  on  bf^th   .sides  above  the  former  p<jint  (»f  . ,.,,  iil.  lion. 


998  STRANGULATED    HERNIA. 

In  this  position  the  loop  is  anchored  by  a  mesenteric  suture  that 
includes  also  the  ring  or  some  other  solid  structure.  Iodoform 
gauze  is  then  packed  around  the  bowel,  above  the  seat  of  the 
constriction,  after  which  the  gangrenous  portion  is  freely  incised 
and  the  parts  thoroughly  cleansed.  Dry  dressings  are  of  no  use 
in  such  cases.  A  hot  moist  antiseptic  compress  is  the  proper 
dressing.  Helferich's  proposal  to  perform  at  the  same  time  a 
laparotomy  and  establish  an  intestinal  anastomosis  between  the 
afferent  and  efferent  limbs  of  the  loop  above  the  constriction  has 
not  met  with  favor  by  the  profession,  for  reasons  so  obvious  that 
it  is  superfluous  to  enumerate  them.  This  operation  has  much  to 
recommend  it  later,  when  it  becomes  desirable  to  close  the  artificial 
anus. 

As  not  infrequently  other  organs  besides  the  mesentery  and 
intestines  find  their  way  into  the  sac  of  a  hernia,  special  care  is 
necessary  to  identify  the  contents.  The  bladder  has  been  re- 
peatedly wounded  before  it  was  recognized.  In  women  the  ovary 
has  been  found  occasionally  in  the  hernial  sac,  and  if  the  seat  of 
disease  is  greatly  damaged  by  the  strangulation,  it  should  be 
removed  in  the  usual  way  after  preliminary  ligation  of  the  pedicle, 
and  the  stump  iodoformized  and  carefully  replaced  into  the  abdom- 
inal cavity. 

Radical  Operation. — In  all  cases  of  strangulated  hernia  treated 
by  operative  reduction  or  the  removal  of  the  contents  of  the  hernial 
sac,  a  radical  operation  for  the  obliteration  of  the  hernial  opening 
should  be  made  if  the  general  condition  of  the  patient  justifies 
prolongation  of  the  anesthesia  and  operation  to  this  extent.  It  is 
advisable  to  resort  to  a  method  of  accomplishing  this  object  with 
the  least  loss  of  time,  and  that,  at  the  same  time,  promises  durable 
results.  ' 

Umbilical  Hej'uia. — In  umbilical  hernia  the  attenuated  skin  is 
removed  with  the  sac.  The  structures  that  furnish  the  most  resist- 
ing part  of  the  abdominal  wall  on  each  side  of  the  linea  alba  must 
be  made  accessible  to  direct  suturing  by  buried  sutures.  The 
wound  surfaces  for  approximation  should  be  broad,  and  all  the 
important  structures  must  be  brought  in  contact  by  separate  rows 
of  sutures.  The  first  step  in  performing  the  radical  operation  con- 
sists in  splitting  freely  the  margins  of  the  wound,  securing  free 
exposure  of  both  recti  muscles.  Ligation  of  the  sac  of  an  umbilical 
hernia  is  always  contraindicated,  even  though  the  hernia  be  a  small 
one.  The  entire  sac  is  excised,  and,  after  splitting  the  margins  of 
the  hernial  opening,  the  wound  is  sutured  in  the  same  manner  as 
after  any  other  abdominal  operation.  During  the  operation  the 
abdominal  contents  are  protected  by  a  dry  compress  of  sterile 
gauze  held  in  the  jaws  of  a  long  hemostatic  forceps.  The  deep 
sutures  of  silkworm-gut,  two  or  three  to  every  inch,  are  first  in- 
serted, but  not  tied.  These  sutures  should  be  made  to  include  the 
entire   thickness    of    the   abdominal   wall    minus    the    peritoneum. 


RADICAL    OPERATION. 


999 


Next,  the  peritoneum  is  sutured  with  fine  catgut  or  silk.  The  next 
row  of  buried  sutures  of  strong  catgut  includes  the  sheath  of  the 
recti  muscles.  After  tying  the  deep  sutures,  the  skin  is  sutured 
separately  with  horsehair.  If  the  hernial  opening  is  large  and  the 
diastasis  of  the  recti  muscles  great,  a  relaxation  suture  of  strong 
silk  in  the  center  of  the  wound  will  guard  against  undue  tension 
on  the  buried  sutures.  The  patient,  on  leaving  the  bed,  must  be 
provided  with  a  well-fitting  abdominal  bandage,  and  instructed  to 
wear  it  during  the  day  for  at  least  three  months. 

Ingiii)ial  Hernia. — The  simplest  and  quickest  method  of  obliter- 
ating the  inguinal  canal  after  extirpation  of  the  sac  is  by  the  Nuss- 
baum-Czerny  operation.  The  sac  is  carefully  separated  from  the 
spermatic  cord  and  the  accompanying  vessels,  and  isolated  as  far  as 
the  internal  inguinal  ring,  or,  still  better,  a  little  beyond  it,  after 
which  the  sac  is  twisted  and  tied  with  a  strong  catgut  ligature  as 
high  up  as  possible.  Below  the  ligature  the  .sac  is  transfixed  with 
a  needle  armed  with  strong  catgut.  The 
ligature  is  cut  in  the  middle,  and  each 
half  of  the  sac  is  tied  separately ;  half 
an  inch  below  the  ligatures  the  sac  is 
amputated.  The  stump,  after  being 
iodoformized,  is  pushed  upward,  the 
pillars  of  the  ring  are  well  exposed, 
and  traction  upon  the  cord  and  vessels 
is  made  in  the  lower  angle  of  the  wound, 
while  the  pillars  are  sutured  together 
with  at  least  four  strong  catgut  sutures. 
Great  care  is  necessary  in  inserting  the 
deep  sutures  to  locate  accurately  and  to 
protect  the  large  vessels  against  injury. 
I  have  personal  knowledge  of  two  cases 
of  vessel  injury  in  operations  for  inguinal 
hernia.  In  one  case  the  femoral  vein  was  punctured,  and  in  the 
other  one  of  the  sutures  was  passed  through  the  femoral  artery, 
the  patient  dying  of  secondary  hemorrhage.  In  inserting  and  tying 
the  lowest  suture  care  must  be  taken  to  leave  sufficient  room  for  the 
cord  and  its  vessels.  The  skin-flap  is  sutured  with  silkworm-gut 
and  horsehair.  The  ideal  dressing  for  a  wound  in  this  locality,  and 
tiiat  requires  no  drainage,  is  by  sealing  it  with  a  few  strips  of  iodo- 
form gauze  or  a  thin  layer  of  aseptic  absorbent  cotton,  held  in  ])lace 
with  collodion.  Over  the  dry  impermeable  cru.st  a  small  aseptic 
dressing  is  applied  and  held  in  place  with  a  broad  .strip  of  adhe.sive 
plaster  and  a  spica  bandage.  The  scrotum,  placed  in  an  elevated 
position,  should  be  included  in  this  dressing. 

Macewen's  operation  for  the  radical  cure  of  inguinal  hernia  has 
yielded  very  satisfactory  results,  and  recommends  itself  as  an  excel- 
lent procedure  as  a  continuation  of  the  operation  of  herniotomy. 
The  principal  feature  of  this  operation  is  the  preservation  <.f  the  sac, 


Fig.  540. — Stripping  the  sac. 


lOOO 


STRANGULATED    HERNIA. 


which  is  utilized  as  a  cushion  over  the  peritoneal  opening  of  the 
inguinal  canal.  The  sac  is  isolated  in  the  usual  way,  a  little  beyond 
the  internal  inguinal  canal,  when  traction  is  made  on  it  so  as  to 
fold  it  properly  for  suturing.  With  a  needle  armed  with  strong  cat- 
gut, knotted  at  one  end,  the  base  of  the  sac  is  transfixed,  after  which 
the  needle  is  passed  through  the  sac  a  number  of  times  in  different 
directions,  until  the  neck  of  the  sac  is  reached  (Fig.  541).  By  mak- 
ing traction  on  the  catgut  thread  the  sac  is  drawn  into  a  solid  pad, 
when  the  free  end  of  the  thread  is  passed  with  the  needle  through 
the  abdominal  wall  on  a  level  with  the  internal  inguinal  ring,  the 
skin  being  drawn  to  one  side.     An  assistant  makes  traction  on  the 


Figs.  541-548. — Mace  wen's  operation  for  the  radical  cure  of  inguinal  hernia. 
Figs.  541-544. — Suture  of  the  hernial  sac. 
Figs.  545-548. — Closing  the  inguinal  canal. 

thread  while  the  ring  is  being  sutured,  and  the  thread  is  fastened  by 
passing  it  several  times  through  the  superficial  fibers  of  the  external 
obHque  muscle.  In  closing  the  inguinal  canal,  Macewen  inserts 
the  sutures  with  two  needles  of  special  construction,  but  the 
ordinary  round  curved  needle  can  be  employed  for  this  purpose. 
As  a  suture  material  Macewen  uses  silver  wire,  but  catgut,  silk- 
worm-gut, or  silk  can  be  used  instead.  The  left  index-finger  is 
introduced  into  the  inguinal  canal,  and  the  epigastric  artery  is  located 
so  as  not  to  include  it  in  the  suture.  Using  the  index-finger  as  a 
guide  for  the  needle,  the  internal  pillar  is  transfixed  at  two  points, 
first  near  the  lower  border,  from  without  inward,  then  above,  from 


BASSINI  S    OPERATION.  1 00 1 

within  the  canal  outward.      With  another  needle  the  lower  end  of 
the  suture  is  then  passed  from  within  outward,  through  Poupart's 
ligament  and  the  conjoined  tendon  ;  in  the  same  manner  the  upper 
end  is  passed  through  the  external  pillar,  when  the 
suture  is  tied  over  the  external  oblique  muscle.     The 
suture  is  tightened  gradually  over  the  tip  of  the  index- 
finger  and  tied  with  sufficient  firmness  to  bring  the 
pillars  in  accurate  contact.      If  the  canal  is  larger, 
two   sutures   are   used   in   closing   it.      The  skin   is 
sutured    separately    with    horsehair    and     silkworm- 
gut,  and  the  wound   dressed  in  the  same  manner  as 
already  described.      If  the  hernia  is  a  congenital  one, 
enough  of  the  lower  part  of  the  sac  is  left  to  furnish 
the  testicle  with   a  tunica  vaginalis,  after  which  the  Fig^^do.— 

upper  part  of  the  sac  is  disposed  of  in  the  manner     Macewen's  op- 
previously  indicated,  and  the   lower  part  is   sutured     eration  for  con- 

^  .     ■'  -11  genital  inguinal 

With    fine    catgut    over    the    testicle,    close    to    the     hernia, 
cord. 

Bassi)n's  Operation. — The  external  incision  advised  by  me  will 
expose  the  inguinal  canal  to  the  best  advantage  for  the  closure  of 
the  inguinal  canal  by  any  of  the  methods  heretofore  advised. 
Bassini's  operation  aims  to  restore  the  obliquity  of  the  inguinal 
canal,  and  to  furnish  it  with  an  anterior  and  a  posterior  wall  that, 
when  brought  in  contact  by  pressure,  close  the  canal  by  a  valve-like 
action.  After  exposing  the  inguinal  canal,  the  aponeurosis  of  the 
external  oblique  muscle  is  incised  from  the  external  inguinal  ring 
the  entire  length  of  the  inguinal  canal,  and  is  reflected  on  both 
sides  in  the  form  of  a  flap.  The  sac  is  next  carefully  isolated  from 
the  cord  and  vessels  as  far  as  the  internal  inguinal  ring,  and,  after 
twisting  it,  is  transfixed  on  a  level  with  the  ring  with  a  needle  armed 
with  a  double  silk  or  catgut  ligature.  Each  .section  is  then  tied 
separately,  and  the  sac  amputated  at  a  safe  distance  below.  On 
elevating  the  spermatic  cord  and  vessels  and  retracting  tlie  apon- 
euro-sis  on  each  side,  Poupart's  ligament  can  be  seen  and  felt  to  the 
point  of  entrance  of  the  cord.  The  external  border  of  the  rectus 
muscle  and  the  conjoined  layers  of  the  internal  oblique,  Iransver- 
salis,  and  transversalis  fascia  are  then  sutured  to  the  po.sterior 
isolated  border  of  Poupart's  ligament  for  a  distance  of  from  three 
to  four  inches,  beginning  at  the  pubes.  The  spermatic  cord  and 
ves.sels  are  brought  into  the  upper  angle  of  the  wound,  and  by 
doing  so  are  displaced  about  hall"  an  inch  outward ;  the  internal  ring 
and  posterior  wall  of  the  inguinal  canal  are  now  estaljlished.  I  he 
.spermatic  cord  is  then  placed  carefully  over  the  line  of  deep  suture.s, 
and  the  aponeuro.sis  sutured  over  it  to  the  lower  angle  of  the  wound, 
which  remains  open,  con.stituting  the  external  inguinal  ring.  The 
external  incision  is  sutured  throughout  and  sealed  with  collodion, 
iodoform  gauze,  and  cotton. 

Hal.sted    has    modifi<.d    P.assini's    operation    by    rccomnKiKhng 


I002 


STRANGULATED    HERNIA. 


excision  of  dilated  spermatic  veins,  and  by  closing  the  canal  with 
mattress  sutures.  Vein  excision  should  be  limited  to  cases  in  which 
the  veins  are  distinctly  varicose,  as  excision  of  normal  veins  is  not 


'■■■■-'■ ., 

'v        \ 

s;v 

^ 

■~f\ . 

w 

•'rf 

1 

Fig.  550. — Bassini's  operation  for  inguinal  hernia:   exposure  of  the  aponeurosis  of  the 
external  oblique  muscle  and  the  external  inguinal  ring. 


Fig-  55I-— ^The  aponeurosis  of  the  external  oblique  muscle  is  divided,  as  well  as 
the  internal  oblique  and  transversalis  muscles  ;  the  spermatic  cord  is  retracted,  and  at 
the  bottom  of  the  wound,  upon  the  peritoneum,  the  epigastric  vessels  can  be  seen.  The 
layer  of  tissue  with  the  sharply  defined  border  is  the  transversalis  fascia. 

essential  to  the  success  of  the  operation  and  is  liable  to  be  followed 
by  atrophy  of  the  testicle. 

Kocher,  Bassini,  and  others  permit  the  patient  to  leave  his  bed 
two  weeks  after  the  operation,  but  I  am  convinced  of  the  necessity 
of  enforced  rest  in  bed  for  at  least  from  three  to  four  weeks.      I 


FEMORAL    HERNIA. 


lOO^ 


consider  it  a  necessary  precaution  in  guarding  against  relapse  by 
yielding  of  the  scar  tissue  under  increased  intra-abdominal  pressure 
incident  to  the  change  from  the  recumbent  to  the  erect  posture. 
If  the  patient  is  confined  to  bed  for  four  weeks  after  the  operation, 
the  subsequent  wearing  of  a  truss  is  more  harmful  than  useful. 


Fig.  552. — Rassini's  operation  for  inguinal  hernia  :  the  muscular  layer  of  the  internal 
oblique  and  the  transversalis  is  attached  by  suture  to  the  inner  border  of  Toupart's  liga- 
ment. In  this  way  the  internal  inguinal  ring  and  the  posterior  wall  of  the  inguinal  canal 
are  formed  anew. 


■'<^,. 


'v. 


^'g-  5S3-— The  aponeurosis  of  ilr  Mique  is  united  over  the  spermatic  cord, 

except  in  the  situation  </l   iij.    new  external  inguinal  ring. 

The  absorbable  suture  is  the  ideal  material  for  closing  thr  m;;..! 
nal  canal,  although   many  surgeons  prefer  silk  (Koclu-r)  or  .silver 
wire  (Halsted). 

Femoral  //r;v//a.— Kx[)osure  of  the  femoral  (in  .1  fioui  i'oupait  .s 


I004  INTESTINAL    FISTULA. 

ligament  to  the  lower  margin  of  the  saphenous  opening  by  the 
curved  incision  and  reflection  of  the  cutaneous  flap  greatly  facihtates 
the  remaining  steps  of  the  radical  operation  (Fig.  535).  Isolation 
of  the  sac  in  femoral  hernia  is  a  much  less  difficult  task  than  in 
ino-uinal  hernia.  The  femoral  vessels  are  the  most  important 
structures  to  be  avoided.  As  in  inguinal  hernia,  isolation  of  the 
sac  should  be  commenced  not  at  the  base,  but  in  the  hernial  canal. 
The  sac  is  liberated  the  entire  length  of  the  crural  canal,  where  it  is 
twisted,  transfixed,  tied,  and  excised  in  the  same  manner  as  in 
inguinal  hernia.  Closure  of  the  crural  canal  by  Salzer's  method  can 
be  relied  upon  as  far  as  safety  and  permanency  of  the  result  are 
concerned.  For  this  purpose  Salzer  employs  a  flap  from  the  firm 
fascia  of  the  pectineus  muscle.  The  flap  is  formed  by  making  a 
curved  inci.sion,  with  the  convexity  directed  downward  from  the 
crista  pectinea  to  Gimbernat's  ligament,  and  is  then  turned  upward 
and  sutured  with  strong  catgut  to  the  lower  margin  of  the  inner 
third  of  Poupart's  ligament.  After  the  flap  has  been  sutured  in 
place,  the  continuity  of  the  sheath  of  the  pectineus  muscle  can  be 
restored  by  a  few  buried  absorbable  sutures.  Care  must  be  exer- 
cised in  suturing  the  flap  not  to  puncture  or  compress  the  femoral 
vessels.  I  have  performed  this  operation  a  great  many  times  and 
have  never  heard  of  a  relapse. 


CHAPTER  XXVII. 
INTESTINAL  FISTULA. 


The  term  intestinal  fistula  is  used  to  signify  the  existence  of  a 
communication  between  the  lumen  of  any  part  of  the  intestinal  tract 
and  the  surface  of  the  body,  or  with  any  of  the  hollow  abdominal 
or  pelvic  viscera.  A  practical  division  must  be  made  as  regards  the 
size  and  character  of  such  abnormal  communication  into  (i)  fistula 
and  (2)  artificial  anus.  The  difference  is  one  of  degree  and  not  of 
kind.  Speaking  from  a  purely  surgical  standpoint,  a  fistula  of  the 
bowel  is  an  opening  through  which  gas  or  a  part  of  the  liquid  and 
solid  intestinal  contents  escapes,  while  an  artificial  anus  implies  a 
complete  interruption  of  the  fecal  circulation  at  the  abnormal  outlet. 
The  latter  condition  is  determined  either  by  the  size  of  the  defect  in 
the  intestinal  wall  or  by  the  existence  of  mechanical  conditions  that 
divert  the  intestinal  contents  in  the  direction  of  the  abnormal  outlet 
and  away  from  the  distal  side  of  the  bowel.  The  mechanical  con- 
ditions that  thus  divert  the  fecal  current  are  either  a  flexion  or  the 
presence  of  a  spur  or  septum  at  a  point  opposite  to  the  abnormal 
outlet,  caused  by  projection  of  the  intact  part  of  the  intestinal  wall 
in  the  direction  of  the  fistulous  opening.    The  surgeon  aims  to  pro- 


ETIOLOGY.  .  1 005 

duce  such  an  obstruction  to  the  fecal  circulation,  when  he  desires  to 
procure  rest  for  the  distal  part  of  the  intestinal  tract,  by  the  forma- 
tion of  an  intentional  artificial  anus.  The  amount  of  intestinal  con- 
tents that  escapes  from  the  intestinal  canal  through  such  an  abnor- 
mal outlet  depends  less  on  the  size  of  the  opening  than  on  the 
existence  of  one  or  both  of  the  above-mentioned  mechanical  condi- 
tions. If  the  intestinal  tube  is  straight  or  only  slightly  curved,  even 
a  large  opening  may  resemble  a  simple  intestinal  fistula,  while,  on 
the  other  hand,  a  small  opening,  associated  with  a  flexion  or  a  well- 
developed  spur,  appears  clinically  as  an  artificial  anus  and  must  be 
treated  as  such.  Internal  fistulae  communicate  most  frequenth'  with 
another  part  of  the  intestinal  tract  (bimucous  fistula  of  Dreschfeld), 
the  bladder,  vagina,  or  uterus. 

Etiology. — Intestinal  fistulae  are  divided  into  (i)  intentional  and 
(2)  accidental.  The  surgeon  occasionally  resorts  to  the  formation 
of  an  intestinal  fistula  or  artificial  anus  in  the  treatment  of  inoper- 
able mechanical  obstruction,  by  resorting  to  a  colostomy  or  an 
enterostomy,  according  to  the  location  of  the  mechanical  obstacle 
that  has  necessitated  the  operation.  If,  in  such  cases,  the  intestinal 
opening  is  to  serve  only  a  temporary  purpose,  it  is  closed  by  opera- 
tive measures  in  the  same  manner  as  will  be  advised  in  the  discus- 
sion of  the  operative  treatment  of  accidental  fistula,  after  the  distal 
part  of  the  intestinal  canal  has  been  rendered  permeable  spontane- 
ously or  by  subsequent  operativ^e  interference. 

Accidental  fistulse  are  produced,  according  to  the  immediate 
cause  :  (i)  By  gunshot  and  stab  wounds  of  the  abdomen  ;  (2)  by 
submural  injury  of  the  bowel  ;  (3)  by  ulceration  of  the  bowel ;  (4) 
by  strangulation  of  the  bowel  ;  (5)  by  foreign  bodies  in  the  intes- 
tinal canal  ;  (6)  by  malignant  tumors  ;  (7)  by  intestinal  actinomy- 
cosis ;  (8)  by  pelvic  and  other  abdominal  abscesses ;  (9)  by  appen- 
dicitis ;  (10)  by  unintentional  injury  to  the  bowel  during  abdominal 
and  pelvic  operations  ;  (i  i)  by  ligatures  ;  (12)  by  sutures  ;  (13)  by 
drainage-tubes. 

Gunshot  and  Stab  Wounds. — These  injuries  usually  result  in 
fatal  septic  peritonitis  if  the  intestinal  wound  or  wounds  are  large 
enough  to  permit  escape  of  fecal  material  into  the  free  peritoneal 
cavity,  and  if  they  are  not  subjected  in  time  to  direct  operative  treat- 
ment. A  fecal  fi.stula,  external  or  internal,  may  result  if  the  wound  is 
small  or  if  only  a  part  of  the  intestinal  wall  has  been  injured,  in  which 
event  the  injured  part  becomes  adherent  to  the  i)arictal  peritoneum 
or  to  an  adjacent  hollow  organ.  A  resulting  circumscribed  ab- 
scess may  later,  under  such  circumstances,  perforate  the  abdom- 
inal wall  or  discharge  its  contents  into  the  adherent  organ  and  thus 
establish  either  an  external  or  an  internal  fistula.  According  to  the 
experience  of  surgeons  during  the  Civil  War,  such  an  <.icuri-ence 
is  more  likely  to  follow  injury  of  the  colon  than  wounds  of  tlw 
small  intestine,  .  , 

Submural    Injury.— Partial    laceration    of  the    intestinal    wall 


I006  .       INTESTINAL    FISTULA. 

without  a  penetrating  wound  of  the  abdomen  occasionally  results 
in  circumscribed  peritonitis,  caused  by  the  migration  of  pathogenic 
microbes  from  the  intestinal  canal  through  the  damaged  wall  to  the 
surface  of  the  bowel,  where,  if  present  in  sufficient  number  and 
virulence,  they  may  produce  an  abscess  that  not  only  completes 
the  intestinal  perforation,  but  may  result  at  the  same  time  in  the 
formation  of  an  external  or  an  internal  fistula.  Such  fistulas  are 
usually  small  and  close  spontaneously  in  the  course  of  time.  In 
suspected  submural  injury  of  the  bowel  without  evidences  of  com- 
plete rupture  and  fecal  extravasation  it  is  of  the  greatest  importance 
to  enforce  efficient  treatment,  with  a  special  view  to  preventing  this 
remote  complication. 

Ulceration. — Ulceration  of  the  bowel  is  frequently  followed  by 
the  formation  of  an  intestinal  fistula  if  the  free  peritoneal  cavity  is 
shut  off  by  adhesions  before  perforation  takes  place  and  if  the  ulcer 
manifests  no  tendency  to  repair.  In  the  upper  part  of  the  intes- 
tinal canal  the  round,  perforating  ulcer  of  the  duodenum  may  pro- 
duce such  a  result.  I  have  observed  two  cases  of  perforating 
typhoid  ulcer  in  which  a  diffuse  abscess  was  formed,  which  was 
freely  incised  and  drained.  In  one  case  the  abscess  cavity  contained 
at  least  a  quart  of  fecal  material  that  had  evidently  been  accumulat- 
ing for  more  than  a  week.  The  patient's  general  condition  was 
such  as  to  contraindicate  search  for  and  suturing  of  the  perforation. 
In  both  cases  life  was  prolonged  for  from  one  to  two  weeks,  but  the 
patients  finally  succumbed  to  sepsis.  It  is  not  difficult  to  conceive 
that  under  more  favorable  circumstances  such  patients  might  re- 
cover, under  similar  treatment,  with  an  intestinal  fistula  that  would 
in  all  probability  heal  spontaneously,  or  could  be  closed  later  by 
operation  with  a  good  prospect  of  success.  From  my  own  per- 
sonal observation  I  am  satisfied  that  the  ulcers  that  terminate  most 
frequently  in  the  formation  of  an  intestinal  fistula  are  of  a  tuber- 
cular character.  I  have  observed  a  number  of  such  instances. 
The  clinical  course  in  such  cases  is  almost  typical.  The  localized 
peri-intestinal  process  is  usually  preceded  by  symptoms  that  point 
to  a  chronic  catarrhal  or  ulcerative  enteritis.  A  painless,  cold 
abscess  appears  at  the  point  where  the  perforated  bowel  has  be- 
come attached  to  the  abdominal  wall.  The  abscess  develops  insidi- 
ously and  progresses  very  slowly.  If  the  abscess  opens  spontane- 
ously or  is  incised,  it  contains,  as  a  rule,  no  fecal  material.  The 
fistula  forms  later,  or  is  produced  at  once  if  the  granulations  lining 
the  abscess  wall  are  scraped  away  with  a  sharp  spoon.  The  com- 
municating opening  between  the  lumen  of  the  bowel  and  the  abscess 
cavity  is  temporarily  blocked  with  granulations,  which,  when  re- 
moved or  when  destroyed  by  suppuration  and  degeneration,  per- 
mit the  establishment  of  the  fistula,  through  Avhich  gas  and  fecal 
contents  escape.  In  one  case  such  an  abscess  was  found  in  the 
umbilical  region,  and  in  another  in  the  right  Hnea  semilunaris.  In 
both  cases  a  fecal  fistula  was  established,  and  the  patients  eventually 


MALIGNANT    TUMORS. 


1007 


died  from  the  effects  of  the  primary  intestinal  affection.  Such 
fistulse  hasten  the  fatal  termination  and  are  seldom  amenable  to 
successful  surgical  treatment.  Tubercular  abscesses  in  communi- 
cation with  a  perforated  intestinal  tubercular  ulcer  should  not  be 
incised.  The  proper  treatment  for  such  cases  is  tapping  of  the 
abscess,  followed  by  injection  of  iodoform  emulsion — a  form  of 
treatment  that  will  postpone,  if  not  prevent,  the  formation  of  an 
intestinal  fistula.  Konig  is  of  the  opinion  that  in  many  cases  of 
tubercular  intestinal  fistula  the  primary  disease  starts  in  the  peri- 
toneum, resulting  in  perforation  of  the  intestine  from  without  in- 
ward. In  such  cases  multiple  fistulse  are  often  established  in  rapid 
succession. 

Strangulation. — The  functional  disturbance  of  the  intestine  fol- 
lowing strangulated  hernia,  terminating  in  gangrene,  without  treat- 
ment or  under  conservative  measures,  will  depend  upon  the  extent 
of  loss  of  mural  tissue,  and  will  vary  from  a  small  fistula  onlj'  large 
enough  to  permit  the  escape  of  gas,  to  a  perfect  artificial  anus. 
Occasionally  such  an  accident  follows  the  reposition  by  taxis  of  a 
damaged  intestinal  loop.  The  Littre,  femoral,  and  properitoneal 
herniae  are  most  likely  to  be  overlooked  by  the  surgeon,  and  conse- 
quently most  frequently  give  rise  to  this  complication. 

Foreign  Bodies. — Perforation  of  the  intestinal  wall  by  a  foreign 
body,  preceded  by  a  circumscribed  plastic  peritonitis,  frequently 
results  in  the  formation  of  an  abscess  that,  when  it  reaches  the  sur- 
face or  an  adjacent  hollow  organ,  is  followed  by  an  intestinal  fistula. 
Small,  slender  foreign  bodies,  such  as  needles,  pins,  and  fish-bones, 
often  perforate  the  intestinal  wall  and  find  their  way  to  the  surfoce 
or  into  neighboring  organs  without  giving  rise  to  an  intestinal  fis- 
tula. In  one  case  I  removed  four  fish-bones  from  a  small  abscess 
in  the  median  line  below  the  umbilicus,  after  which  the  abscess 
healed  promptly  and  permanently.  The  foreign  bodies  that  are 
most  frequently  found  in  abscesses  preceding  intestinal  fistula  are 
sharp  fragments  of  bone,  gall-stones,  and  enteroliths. 

Malignant  Tumors. — Malignant  tumors  may  cause  intestinal 
fistula  either  by  producing  obstruction,  followed  by  distention  and 
ulceration  on  the  proximal  side,  or  by  directly  implicating  the  intes- 
tinal wall.  The  latter  mode  of  origin  is  the  most  common.  The 
malignant  tumor  in  such  instances  invades  by  contiguity  the  part  or 
organ  that  becomes  the  seat  of  the  intestinal  fistula,  and  at  the  .same 
time  perforates  the  intestinal  wall,  so  that  the  fistula  is  surrounded 
everywhere  by  malignant  tissue.  Carcinoma  more  frecjuently  pur- 
sues such  a  course  than  sarcoma.  Pyogenic  infection  of  the 
malignant  tumor  frequently  plays  an  important  role  in  such  cases. 
The  suppurative  infection  often  overshadows  the  malignant  disca.se 
so  completely  that  the  surgeon  is  misled  in  his  diagno.sis  and  insti- 
tutes treatment  appropriate  for  abscess  when  the  operation  reveals  a 
malignant  tumor  as  the  foundation  of  the  difficulty.  Carcinoma  ot 
the  cecum  complicated  by  suppuration  has  been  repeated!)-  mistaken 


I008  INTESTINAL    FISTULA. 

for  appendicitis.  Carcinoma  of  the  sigmoid  flexure  and  cecum 
occasionally  results  in  a  pathologic  anastomosis  between  the  affected 
part  of  the  bowel  and  an  adjacent  loop  of  the  small  intestine. 
Carcinoma  of  the  upper  part  of  the  rectum  only  too  often  invades 
the  bladder  and  results  in  the  formation  of  a  rectovesical  fistula. 
Carcinoma  of  the  stomach  and  transverse  colon  has  resulted  in 
pathologic  gastrocolostomy. 

Actinomycosis. — A  number  of  cases  of  intestinal  actinomycosis 
have  been  recorded  in  which  the  disease  in  its  course  perforated  the 
intestinal  wall  and  gave  rise  to  diffuse  abscesses  and  intestinal  fistula. 
The  ileocecal  region  is  the  favorite  locality  for  such  processes.  In 
the  only  case  of  this  kind  that  came  under  my  own  observation  the 
disease  originated  evidently  in  the  ileocecal  region,  but  the  abscess 
reached  the  cavity  of  Retzius  and  was  opened  in  the  median  line, 
above  the  pubes. 

Pelvic  and  Abdominal  Abscesses. — By  far  the  most  frequent 
causes  of  intestinal  fistula  are  pelvic  and  abdominal  abscesses.  Such 
abscesses  sometimes  are  caused  by  migration  of  pyogenic  microbes 
through  a  damaged  or  inflamed  intestinal  wall,  perforate  later  the 
intestine,  and  finally  open  or  are  incised  on  the  surface,  when  the  fistula 
is  completed.  The  fistulous  tract  is  often  long  and  tortuous.  More 
commonly  a  pyosalpinx  or  acute  phlegmonous  abscess  of  the  para- 
uterine connective  tissue  pursues  such  a  course.  Such  abscesses 
open  most  frequently  into  the  rectum,  bladder,  and  intestinal  coils 
upon  the  floor  of  the  pelvis,  but  they  may  open  into  the  cecum  and 
sigmoid  flexure.  Externally  they  point  most  generally  in  the  groin, 
but  they  may  also  reach  the  surface  through  the  sacrosciatic  notch, 
and  occasionally  extend  to  the  lumbar  region.  The  external  fistu- 
lous opening  may  be  found  in  any  of  these  localities.  Not  in- 
frequent causes  of  intestinal  fistula  are  tubercular  abscesses  resulting 
from  tubercular  spondylitis  and  tuberculosis  of  the  pelvic  bones.  In 
some  cases  the  abscess  is  discharged  first  into  the  cecum  or  rectum ; 
not  so  often  into  other  parts  of  the  large  and  the  small  intestine, 
and  later  reaches  the  surface ;  or  the  fistula  forms  in  the  course  of 
suppurating  tubercular  tracts.  Rectal  insufflation  is  an  exceedingly 
valuable  diagnostic  test,  not  only  for  the  purpose  of  ascertaining 
whether  or  not  the  fistulous  tract  communicates  with  the  intestine, 
but  also  in  demonstrating  the  exact  location  of  the  intestinal  per- 
foration. 

Appendicitis. — Appendicitis  is  the  most  frequent  cause  of  intes- 
tinal fistula  in  the  ileocecal  region.  The  fistula  is  produced  in  one 
of  two  ways  :  (i)  By  sloughing  or  perforation  of  the  appendix  ;  (2) 
by  rupture  of  an  abscess  of  appendicular  origin  into  the  cecum  or 
adjoining  intestinal  loops,  with  the  subsequent  formation  of  an 
external  opening.  If,  in  gangrenous  appendicitis,  the  entire  appendix 
is  cast  off  as  a  slough  with  the  contents  of  the  abscess,  the  fistulous 
opening  involves  the  cecum  and  occupies  that  part  of  the  bowel 
to  which  the   appendix  was  attached.      Clinically  such  a  fistula  re- 


TRAUMA    OF    BOWEL. 


1009 


sembles  a  cecal  fistula  produced  by  other  causes.  In  partial  gan- 
grene of  the  appendix  and  perforation  of  the  organ  treated  upon  the 
expectant  plan,  by  incision  and  drainage,  without  removal  of  the  ap- 
pendix, if  a  fistula  persists,  the  remaining  lumen  of  the  appendix  com- 
municates with  the  cecum  on  one  side  and  the  external  fistulous 
tract  on  the  other.  The  fistulous  opening  into  the  bowel  under  these 
circumstances  is  so  small  that  seldom  anything  but  gas  escapes. 
Such  fistula;  occasionally  heal  spontaneously  in  the  course  of  a  few 
weeks  ;  but  after  it  has  become  well  established,  closure  of  the  fistula 
without  operation  is  not  to  be  expected.  A  paratyphlitic  abscess 
rupturing  into  the  cecum  often  terminates  in  a  permanent  cure,  but 
sometimes  it  results  in  extensive  destruction  of  the  cecal  wall,  fol- 
lowed by  the  formation  of  a  correspondingly  large  fistulous  opening. 
The  location  of  the  cecal  opening  will  vary  according  to  the  situ- 
ation of  the  abscess.  The  cases  of  cecal  fistula  that  have  come 
under  my  own  observation  involved  either  the  anterior  or  the  pos- 
terior wall  ;  but  it  may  affect  any  part  of  the  cecum,  and  occasionally 
the  abscess  ascends  in  the  direction  of  the  ascending  colon,  which  it 
may  perforate,  causing  a  fistula  of  this  part  of  the  large  intestine.  I 
have  seen  three  cases  of  fistula  of  the  cecum  following  appendicitis  in 
which  the  opening  in  the  abdominal  wall  and  cecum  was  large 
enough  to  in.sert  three  fingers.  In  all  these  cases  the  fecal  current 
was  arrested  at  the  opening  by  the  presence  of  an  effective  spur, 
formed  by  the  ]^rojection  of  the  opposite  wall  toward  the  opening 
in  the  cecum.  It  is  in  cases  of  this  kind,  if  the  abscess  has  been 
opened  by  the  surgeon,  that  he  is  charged  by  the  patients  and  friends 
witli  having  cut  the  bowel,  when  in  reality  the  intestinal  opening 
either  was  present  at  the  time  the  operation  was  made  or  occurred 
later  by  sloughing  of  the  inflamed  cecal  wall. 

Injury  of  Bowel  During  Abdominal  and  Pelvic  Operations. — 
Under  this  head  it  is  not  intended  to  discuss  those  gross  lesions  of 
the  intestines  occurring  during  abdominal  and  pelvic  operations  that 
the  surgeon  recognizes  and  treats  at  once.  Reference  will  be  made 
more  particularly  to  (overlooked  and  incomplete  wounds  of  the 
bowel  as  causes  of  intestinal  fistula.  Modern  gynecology  encour- 
ages heroic  attempts  in  the  removal  of  abdominal  and  pelvic  tumors 
that  only  a  few  years  ago  would  have  been  regartled  by  the  boldest 
surgeons  as  inoperable.  The  removal  of  adherent  tumors  and  pus- 
tubes  brings  the  operator  often  in  very  cIo.se  contact  with  the  intes- 
tines. The  inflammatory  processes  that  have  produced  the  firm 
adhesions  have  often  resulterl  in  great  damage  to  the  adherent  part 
of  the  intestine.  The  intestinal  wall,  from  pressure,  cicatricial  con- 
traction, and  impaired  nutrition,  is  often  found  not  much  thicker 
than  ordinary  writing-pajK-r.  hence  exccedingl\'  lial)le  to  be  torn 
during  the  .separation  of  firm  adhesions.  I  he  intestine  attached  to 
a  tumor  or  pelvic  abscess  by  firm  and  old  adhe.sions  has  lost  its 
outer  or  peritoneal  coat  over  an  area  corresponding  with  the  extent 
of  the  adhesion.s.  Unless  the  surg«(,n  ob.serves  the  necessary  pre- 
64 


lOIO  INTESTINAL    FISTULA. 

caution  of  making  the  detachment  at  the  expense  of  the  tumor  or 
tube,  if  he  does  not  tear  an  opening  into  the  bowel  he  will,  at  least, 
seriously  damage  the  intestinal  wall.  There  can  be  but  little  doubt 
that  in  numerous  instances  of  this  kind  surgeons  have  overlooked 
minute  perforations  in  the  bowel  that,  if  they  did  not  result  in  fatal 
septic  peritonitis,  became  the  direct  source  later  of  an  intestinal 
fistula.  It  must  also  be  remembered  that  a  greatly  damaged  intes- 
tinal wall  is  permeable  to  pyogenic  microbes,  and  consequently 
becomes  not  infrequently  the  sole  cause  of  a  late  infection  after 
laparotomy,  and,  if  the  patient  survives,  of  abscess  and  intestinal 
fistula.  Every  experienced  surgeon  will  recall  such  mishaps  when 
he  could  assure  himself  that  in  other  respects  the  operation  was  fault- 
lessly performed.  The  examination  of  detached  intestinal  loops  for 
perforations  or  other  serious  damage  should  not  be  postponed  until 
completion  of  the  operation,  as  it  may  be  impossible  to  find  them 
again  at  that  time.  The  inspection  should  be  made  at  once,  and  all 
defects  remedied  before  additional  adhesions  are  separated.  By 
pursuing  such  a  course,  and  by  detaching  the  adhesions  at  the  expense 
vf  the  part  to  be  removed,  zve  shall  hear  less  in  the  future  of  septic 
peritonitis,  abscess,  and  intestinal  fistida  arising  from  this  cause  after 
laparotomy. 

Ligatures. — In  small  wounds  and  limited  gangrene  of  the  bowel 
Astley  Cooper  made  a  small  cone,  the  apex  of  which  corresponded 
with  the  injury  or  disease,  and  applied  a  hgature  of  fine  silk  around 
the  base.  The  ligature  cuts  its  way  into  the  lumen  of  the  bowel 
during  the  time  the  resulting  defect  becomes  sealed  by  plastic  lymph. 
It  can  readily  be  conceived  under  what  circumstances  such  a  proce- 
dure would  prove  safe  and  efficient.  If  the  parts  included  in  the 
ligature  and  the  ligature  itself  are  aseptic,  the  formation  of  a  fistula 
is  prevented  by  the  production  of  new  tissue  around  the  ligature  and 
included  mass  before  the  ligature  reaches  the  lumen  of  the  bowel. 
If,  on  the  other  hand,  the  asepsis  is  not  perfect  and  suppuration 
occurs  in  the  track  of  the  Hgature,  an  intestinal  perforation  is  very 
likely  to  ensue.  After  separation  of  adherent  intestine  bleeding 
points  are  often  tied  with  silk.  Isolation  of  the  bleeding  vessel  is 
usually  out  of  the  question,  and  more  or  less  of  bowel  tissue  is 
included  in  the  ligature.  It  must  not  be  forgotten  that  under  such 
conditions  the  bowel  has  been  deprived  of  its  peritoneal  investment, 
and  consequently  the  facihties  for  encapsulation  of  the  ligature  are 
diminished.  If  to  this  is  added  an  extremely  attenuated  bowel -wall, 
it  is  not  difficult  to  understand  in  what  way  a  Hgature  may  some- 
times give  rise  to  a  late  perforation,  peritonitis,  abscess,  and  intesti- 
nal fistula. 

Sutures. — Careless  suturing  of  the  abdominal  incision  is  respon- 
sible for  many  accidents  to  the  intestines.  Undue  haste  in 
completing  this  part  of  the  operation  is  often  severely  punished. 
Unless  the  operator  resorts  to  proper  precautions,  the  needle 
may  transfix  a  part  of  the  circumference  of  the  small  intestine  ; 


DRAINAGE-TUBES.  lOII 

on  tying  the  suture,  the  loop  is  anchored  against  the  external 
incision,  the  ligature  later  cuts  its  way  through  the  included  part 
of  the  bowel,  and,  if  a  fatal  peritonitis  does  not  result,  an  intestinal 
fistula  is  sure  to  follow.  I  have  seen  two  cases,  occurring  in  the 
practice  of  distinguished  surgeons,  where  there  was  good  reason 
to  believe  that  the  intestinal  fistula  had  such  an  origin.  But  this 
is  not  the  only  way  in  which  sutures  have  produced  this  compli- 
cation. Unless  the  peritoneum  is  sutured  separately,  in  tying  the 
deep  sutures  a  loop  of  the  underlying  intestines  may  be  caught 
between  the  sutures  and  the  abdominal  wall,  and,  on  tightening  the 
sutures,  strangulation  results,  followed  by  intestinal  obstruction, 
gangrene  of  the  strangulated  part  of  the  bowel  or  coil,  abscess,  and 
fistula.  Again,  an  intestinal  coil  may  escape  between  the  sutures 
and  become  strangulated  between  the  margins  of  the  wound,  with 
similar  consequences.  It  is  time  that  surgeons  should  recognize  the 
suture  as  a  cause  of  such  complications  and  resort  to  efficient  pro- 
phylactic measures.  I  am  strongly  convinced  of  the  value  of  a 
separate  row^  of  buried  absorbable  peritoneal  sutures  in  closing  the 
abdominal  incision,  both  for  the  purpose  of  guarding  against  acci- 
dents to  the  intestines  and  as  a  prophylactic  measure  against  ven- 
tral hernia.  Whenever  it  is  possible,  the  omentum  should  be  drawn 
downward  far  enough  to  cover  the  entire  length  of  the  incision. 
The  use  of  the  aseptic  compress  as  an  aid  in  suturing  the  external 
wound  is  so  well  known  that  it  is  necessary  only  to  mention  it  in 
connection  with  this  subject. 

Drainage=tubes. — The  last,  but  by  no  means  the  lea.st,  impor- 
tant subject  that  will  be  discussed  in  connection  with  the  etiology 
of  intestinal  fistula  is  the  drainage-tube.  Prolonged  tubular  drain- 
age with  glass  or  rubber  tubes  is  a  well-known  factor  in  the  produc- 
tion of  intestinal  fi.stula.  The  opening  in  the  bowel  is  produced  by 
pressure  atrophy.  I  am  inclined  to  believe  that  the  elastic  pressure 
caused  by  rubber  drains  is  more  injurious  than  that  exerted  by  glass 
tubes.  Long-continued  tubular  drainage  for  supi)urative  lesions  is 
more  dangerous  in  this  respect  than  similar  methods  of  drainage 
for  parenchymatous  oozing  or  other  aseptic  pathologic  conditions. 
In  the  former  case  the  suppuratixe  inflammation  along  the  drainage 
canal  adds  to  the  destructive  effect  of  pressure.  It  will  be  difficult, 
if  not  impo.s.sible,  to  eliminate  entirely  this  etiologic  element  by  any 
amount  of  care  in  cases  requiring  long-continueti  tubular  drainage. 
In  recent  ca.ses  nece.ssitating  drainage  for  a  few  days  it  is  advisable 
to  surround  the  gla.ss  or  rubber  drain  with  a  few  layers  of  iodoform 
gauze,  for  the  purpo.se  of  diminishing  the  harmful  effects  of  localized 
pressure.  In  drainage  for  supjjurative  affections  it  is  well,  for  the 
same  rea.son,  to  reduce  gradually  the  size  of  the  tube,  and,  when- 
ever practicable,  interpose  between  the  intestine  and  the  tube  a  few 
layers  of  iodoform  gauze. 

Treatment. — The  treatment  of  an  intestinal  fi.stula  mu.st  have 
for  its  aim  closure  of  the  abnormal  opening,  with  as  little  interference 


IOI2 


INTESTINAL    FISTULA. 


as  possible  with  the  lumen  of  the  bowel.  The  statement  has  been 
made,  and  is  borne  out  by  clinical  experience,  that  many  intestinal 
fistulse  close  spontaneously.  This  favorable  termination  may  be 
expected  in  cases  in  which  the  opening  in  the  bowel  is  small,  the 
immediate  cause  of  a  benign  and  temporary  character,  the  general 
health  of  the  patient  not  much  impaired,  and  the  fistulous  opening 
in  the  bowel  so  located  that  it  can  readily  become  attached  to  the 
parietal  peritoneum  or  the  serous  investment  of  an  adjacent  organ. 
The  spontaneous  healing  of  an  intestinal  perforation  is  always  fol- 
lowed by  permanent  parietal  or  visceral  adhesions.  In  fistulae 
resulting  from  tuberculosis,  malignant  disease,  and  actinomycosis, 
spontaneous  heaHng,  from  the  very  nature  of  the  primary  cause,  is 
out  of  the  question,  and,  in  the  majority  of  these  cases,  operative 
treatment  with  a  view  of  closing  the  fistula  is  contraindicated.  The 
operative  treatment  in  such  cases  deserves  consideration  only  in  the 
event  that  the  primary  cause  can  be  completely  eliminated  before  an 
attempt  is  made  to  restore  the  continuity  of  the  bowel.  In  fistula 
caused  by  malignant  disease,  in  which  the  extent  of  the  primary 
cause  has  rendered  a  radical  operation  inapplicable,  it  may  be  advisa- 
ble to  secure  rest  for  the  diseased  part  of  the  intestine  by  establish- 
ing an  artificial  anus  on  the  proximal  side.  In  the  treatment  ot 
tubercular  and  actinomycotic  fistula;  the  primary  disease  must 
receive  proper  attention,  and,  in  case  it  is  amenable  to  successful 
treatment,  the  fistula  will  heal  spontaneously  or  is  subjected  later  to 
appropriate  surgical  treatment. 


Fig.    554. — Intestinal   fistula  without  Fig.  555. — Intestinal   fistula  lined  by  the 
lining  of  mucous  membrane  :  a.  Abdominal  mucous  membrane  of  the  bowel, 

wall ;  b,  intestinal  wall ;  c,  mucous  mem- 
brane ;  d,  fistula. 


Pathologic  Anatomy  of  Intestinal  Fistula. — For  the  sake  of 
simplicity  the  different  forms  of  intestinal  fistula  will  be  described  as 
they  are  observed  on  the  surface  of  the  body,  although  the  same 
remarks  will  apply  to  the  internal  fistulae,  where  similar  conditions 
are  developed. 

Intestinal  Fistula. — Intestinal  fistula,  as  defined  in  the  intro- 
ductory remarks,  presents  itself  in  one  of  two  forms  :  (i)  A  fistulous 
tract  leads  from  the  surface  to  the  opening  in  the  intestine.  (2)  The 
mucous  membrane  of  the  intestine  lines  the  fistulous  tract  and  is  con- 
tinuous with  the  skin  on  one  side  and  the  mucous  lining  of  the  intes- 
tine on  the  other.  In  the  first  variety  the  opening  in  the  bowel  is 
more  or  less  distant  from  the  surface,  and  the  tract  is  lined  by  gran- 


ARTIFICIAL    ANUS. 


IOI3 


Fig.  556. — Intestinal  fistula  with  llexion. 


ulations.  In  the  second  variety  the  intestinal  wall  reaches  the  sur- 
face, and  the  margins  of  the  opening  in  the  bowel  form  the  border 
of  the  external  opening,  the  entire  fistulous  tract  being  lined  by 
mucous  membrane.  In  both  instances  the  opening  in  the  bowel  is 
lateral,  the  intestinal  tube  either  straight  or  slightK-^  curved,  present- 
ing no  mechanical  impedi- 
ments to  the  fecal  current. 

Artificial  Anus. — The  in- 
terruption, partial  or  complete, 
of  the  fecal  current  at  or  in 
the  immediate  vicinity  of  the 
fistula  is  usually  due  to  one 
of  three  causes  :  (i)  Intestinal 
obstruction  below  the  fi.stula; 
(2)  flexion  of  the  bowel  at  a 

point  corresponding  with  the  location  of  the  fisttda;  (3)  the  presence 
of  a  spur  opposite  the  opening  in  the  bowel.  If  perforation  of  the 
bowel  takes  place  in  consequence  of  an  intestinal  obstruction,  the 
cause  or  causes  that  have  given  rise  to  this  accident  maintain  the 
obstruction,  and  all  the  intestinal  contents  escape  through  the  fistula, 
which  then  serves  the  purpose  of  an  artificial  anus.  If  the  perforated 
part  of  the  bowel  becomes  flexed  by  adhesions  or  otherwi.se,  the 
flexion  narrows  the  lumen  of  the  bowel  and  directs  the  fecal  cur- 
rent toward  the  abnormal  outlet.  Under  such  circumstances  a  con- 
siderable part  of  the  intestinal  contents  neces.sarily  escapes  through 
the  fistulous  opening.  If  the  flexion  becomes  more  acute,  the 
intestinal  wall  opposite  the  opening  forms  a  spur, — promontoriuin 
(Scarpa),  eperon  (Dupuytren), — which,  when  fully  developed,  com- 
pletely intercepts  the  fecal  current  and  transforms  the  fisttilotis 
opening  into  an  artificial  anus. 

From  the.se  remarks  and  the  accompanying  drawings  it  will 
readily  be  seen  that  .spontaneous  healing  can  be  expected  only  in 
cases  in  which  the  fistulous  tract  is  not  lined  by  mucous  membrane 
and  in  which  the  fecal  current  meets  witli  no  impediment  by  flexion 

or  spur  formation.  As  the 
fistulous  opening  in  llie 
bowel  is  often  beyond  the 
reach  of  an  examination  to 
determine  the  actual  condi- 
tions, time  i)lays  an  import- 
ant part  in  enabling  the  sur- 
geon to  determine  whether 
or  not  surgical  interference 
is  necessary.  In  the  absence  of  an  indicado  vitalis,  an  operation 
should  be  postponed  until  the  clinical  course  has  dcmonstatcd  that 
nature's  resources  arc  inadequate  to  accomplish  the  desired  object. 
An  early  operation  is  demanded  if  the  fistula  involve  the  upper  part 
of  the  small  intestine  and  the  escape  of  chyle  endangers  life   from 


Fig.  557- 


.Ailiticiiil  anus:  a.   Spur;   /^  diieclioM 
of  fecal  current. 


IOI4  INTESTINAL    FISTULA.- 

inanition.  In  the  absence  of  such  an  indication,  and  in  the  absence 
of  positive  proof  that  spontaneous  heaHng  is  impossible,  conservative 
treatment  should  be  continued  until  the  indications  for  a  radical  op- 
eration are  established.  A  carefully  selected  diet,  attention  to  the 
condition  of  the  bowels,  rest,  compression  over  the  fistulous  tract, 
and  antiseptic  treatment  of  the  suppurating  tract  comprise  the  lead- 
ing indications  of  the  expectant  treatment. 

Surgical  Treatment. — The  surgical  treatment  must  be  gov- 
erned by  the  pathologic  conditions  that  characterize  each  individual 
case.  A  careful  inquiry  concerning  the  etiology  and  pathology  in 
each  case  is  therefore  necessary  in  order  to  enable  the  surgeon  to 
select  the  appropriate  therapeutic  resources. 

Cauterization. — Cauterization  of  the  fistulous  tract  is  useful  not 
only  in  expediting  spontaneous  healing  in  cases  in  which  such  a 
result  is  to  be  anticipated,  but  also  for  the  purpose  of  removing 
anatomic  conditions  incompatible  with  such  a  termination.  Nitrate 
of  silver  is  most  efficient  in  stimulating  the  process  of  repair  in  cases 
in  which  the  tract  is  lined  by  flabby,  infected  granulations.  Benefit 
from  this  agent  can  be  expected  only  if  it  can  be  applied  the  whole 
length  of  the  canal.  Its  application  is  worse  than  useless  if  the 
entire  tract  is  not  accessible,  on  account  of  either  its  length  or  its 
tortuous  direction.  If  the  fistulous  tract  is  lined  by  mucous  mem- 
brane, is  short  and  readily  accessible  in  its  whole  length,  the  needle- 
point of  the  Paquelin  cautery  can  be  resorted  to  with  advantage. 
The  cauterization  must  be  made  deep  enough  to  destroy  the  entire 
thickness  of  the  mucous  membrane.  On  separation  of  the  tubular 
eschar  the  fistulous  opening  is  enlarged,  and  for  a  time  more  of  the 
intestinal  contents  escape  through  it ;  but  in  a  short  time  the  canal 
becomes  blocked  by  granulations,  which  eventually  result  in  its 
closure.  Before  using  the  cautery  the  length  of  the  tract  must  be 
carefully  determined,  in  order  to  protect  the  bowel  against  injury 
from  the  point  of  the  instrument.  The  same  instrument  is  of  value 
in  the  treatment  of  larger  fistulae,  lined  by  mucous  membrane,  not 
complicated  by  mechanical  impediments  to  the  fecal  circulation.  I 
have  resorted  to  this  procedure  in  a  number  of  cases  of  surface 
fistulae  lined  by  mucous  membrane,  and  have  been  well  satisfied 
with  the  results.  Cauterization  may  sometimes  be  employed 
advantageously  in  the  treatment  of  internal  intestinal  fistula,  as 
shown  by  the  following  case,  recently  examined  and  treated  before 
the  class  at  Rush  Medical  College : 

The  patient  was  a  housewife  twenty-five  years  of  age,  with  a  good  family  history. 
The  present  trouble  dates  back  to  childbirth,  five  and  one-half  years  ago.  Soon  after 
confinement  she  suffered  from  suppurative  mastitis.  Five  years  ago  she  had  an  attack  of 
what  was  called  inflammation  of  the  bowels,  followed  by  diarrhea,  and  was  confined  to 
bed  two  weeks.  Later  the  diarrhea  alternated  with  constipation.  Two  and  one-half  years 
ago  an  abscess  formed  in  the  left  ischiorectal  fossa,  rupturing  two  inches  from  the  anus 
within  two  or  three  months.  Stools  later  contained  blood  but  no  pus.  Second  opening 
appeared  six  months  after  in  left  inguinal  region,  from  which  gas  and  fecal  matter 
escaped  from  the  first,  then  intestinal  contents  from  the  first  opening.  Rectal  examina- 
tion revealed  an  indurated  area  about  four  inches  above  the  anus,  in  the  center  of  which 


DRAINAGE    OF    ABSCESS    CAVITY. 


1015 


a  small  opening  could  be  felt.  The  patient  was  brought  to  the  clinic  with  the  expecta- 
tion that  a  laparotomy  would  be  made  for  the  treatment  of  the  intestinal  fistula.  Injec- 
tion of  peroxid  of  hydrogen  through  the  inguinal  fistula  was  followed  by  the  escape  of 
white  foam  from  the  opening  in  the  rectum,  which  could  be  plainly  seen  through  a 
rectal  speculum.  The  same  was  observed  following  a  similar  injection  into  the  perineal 
fistula,  showing  that  both  abscess  cavities  communicated  with  the  same  intestinal  fistula. 
It  was  decided  to  close  the  rectal  opening  first.  The  patient  was  placed  under  the 
influence  of  an  anesthetic,  and,  while  in  the  Trendelenburg  position,  the  rectal  opening 
was  freely  exposed  by  using  two  Sims  specula.  A  probe  was  passed  from  the  rectum 
into  the  abscess  cavity,  serving  as  a  guide  to  the  needle-point  of  the  Paquelin  cautery, 
with  which  the  fistulous  tract  was  thoroughly  cauterized.  For  a  few  davs  more  fecal 
matter  escaped  through  the  fistula,  but  in  the  course  of  a  week  the  cauterized  tract  was 
found  blocked  by  granulations  that  prevented  even  the  escape  of  gas.  The  patient  con- 
tinued to  improve,  and  in  a  few  weeks  the  abscess  cavity  was  healed  and  the  rectal  fistula 
permanently  closed. 

Drainage  of  Abscess  Cavity. — An  abscess  ca\it\'  interposed 
between  the  intestinal  opening  and  tlie  fistulous  tract  on  the  surface 
or  in  one  of  the  pehic  organs  often  constitutes  an  insurmountable 
obstacle  to  spontaneous  healing.  In  many  ca.ses  the  abscess  cavity 
is  imperfectly  drained  and  is  being  continually  contaminated  by 
fecal  material.  If  the  abscess  is  so  located  that  it  can  be  safely  and 
more  efficiently  drained,  this  procedure  will  often  accomplish  all 
that  is  desired.  This  method  of  treatment  is  particularly  indicated 
in  pelvic  abscesses  complicated  by  intestinal  fistula.  It  must,  how- 
ever, not  be  forgotten  that  under  such  circumstances  the  organs 
in  the  vicinity  of  the  abscess  are  often  di.splaced  by  inflammatory 
adhesions  and  exposed  to  injury  in  efforts  to  secure  better  drain- 
age.     The  following  case  will  serve  as  an  instructive  illustration  : 

A  woman  thirty-five  years  of  age  applied  for  treatment  of  an  intestinal  fistula  in  the 
left  groin.  The  fistula  followed  a  pelvic  abscess  that  was  opened  above  I'oupart's  liga- 
ment. Several  weeks  later  gas  and  fecal  matter  escajied  through  the  fistula.  This  con- 
dition had  existed  for  two  years.  Periodic  discharge  of  increased  (juantity  of  pus  indi- 
cated that  the  original  abscess  cavity  had  not  obliterated,  owing  to  imi>erfect  drainage. 
•As  no  swelling  could  be  felt  in  the  left  parametrium,  it  was  decided  to  drain  the  abscess 
into  the  vagina.  Under  anesthesia  the  external  o|)cning  was  enlarged  .sufiuiently  to 
enable  the  surgeon  to  follow  the  tortuous  canal  into  the  pelvis  to  the  left  side  of  the 
uterus.  With  the  left  index-finger  in  the  vagina  the  point  of  a  large  pair  of  hemostatic 
forceps  could  be  felt  when  the  instrument  was  pushed  through  the  tissues  and  the  mucous 
membrane  incised  over  its  point.  The  canal  was  dilated,  and  a  rubber  drain,  half  an 
inch  in  diameter,  drawn  through,  thus  establishing  through  drainage.  The  jibsce.ss  cavity 
was  thoroughly  irrigated,  \\hen  the  patient  was  seen  the  next  day,  no  urine  had  been 
passed  through  the  urethra  .since  the  0]>eration.  The  bed  was  found  saturated  with  urine. 
Suspecting  what  had  hai)|)ened,  warm  boric  acid  solution  was  injected  into  the  bladder, 
which  at  once  escaped  through  the  vaginal  portion  of  the  drain.  It  was  evident  that  in 
making  the  tunnel  the  forceps  had  transfixed  the  di>i)lac<<l  bladder.  The  drain  was 
removed,  and  a  Sims  catheter  inserted  into  tin-  bladder.  The  drainage  of  the  aiiscess 
cavity  from  the  surface  was  continued.  The  wounds  in  llie  bladder  healed  under  (his 
simple  treatment  in  the  course  of  a  week,  and  a  few  weeks  later  the  fistulous  opening 
closed  permanently. 

Mechanical  Repression  of  Spur. — The  sjmu-  has  bi<n  ivk.-- 
ni/ed  as  a  cause  of  the  persistence  of  intestinal  fistula  for  a  long 
time,  and  different  methods  of  treatment  have  been  devised  for  its 
removal.  Dcsault  advi.sed  the  insertion  of  a  roll  of  dvdrpic  into  the 
bowel,  with  a  view  to  increasing  the  .si/.e  of  the  lumen  of  the  bowel 
and  of  repressing  the  spur,  lianks  inserted  a  large  rubber  tube, 
which   he  fastened  in    the  fistula,  for   the   .same  piirpo.se.      As  the 


ioi6 


INTESTINAL    FISTULA. 


formation  of  the  spur  takes  place  in  consequence  of  the  flexion  of 
the  bowel,  we  can  readily  understand  why  all  such  mechanical 
devices  have  proved  of  so  little  value. 

Removal  of   Spur. — The  first   efforts   to   remove   the  spur  by 


Fig.  558. — Dupuytren's  enterotome. 


Fig.  559. — Dupuytren's  enterotome,  modified  and  improved  by  Blasius.     The  instrument 
is  applied  to  the  spur  in  the  manner  shown  in  figure  560. 

operative  procedure  were  made  by  Schmalkalden  in  1795.  He 
removed  the  spur  with  scissors  and  knife.  The  disastrous  results 
that  must  necessarily  have  followed  this  operation  led  Dupuytren  to 
accomplish  the  same  object  by  a  bloodless  method.      He  devised  for 

this  purpose  a  clamp  (en- 
terotome )  ( Figs.  558— 
560)  which  he  applied 
to  the  spur,  and,  by 
tightening  the  screws 
connecting  the  branches, 
made  it  cut  its  way 
through  the  tissues  by 
causing  linear  necrosis 
of  that  part  of  the  sep- 
tum included  in  its 
branches.  The  instru- 
ment effects  its  object  in 
from  three  to  eight  days. 
It  is  then  again  applied 
on  the  side  of  the  linear 
section,  and  the  same 
procedure  is  repeated  until  the  spur  is  removed.  The  results  of  this 
operation  were  quite  satisfactory  before  laparotomy  was  made  a 
safer  procedure. 


Fig.  560.  —  Treatment  of  artificial  anus  by  Du- 
puytren's clamp  :  a,  Enterotome  applied  ;  b,  the  spur 
in  section  ;  c,  bowel  after  removal  of  spur  (after  Es- 
march). 


CLOSURE    OF    FISTULA    BY    PLASTIC    OPERATION. 


IOI7 


In  1824  Dupuytren  reported  41  cases,  of  which  number  29 
were  cured  and  only  3  died.  Later  Heinniann  collected  83  cases, 
with  a  mortality  of  4.83  per  cent.  The  most  recent  statistics  col- 
lected by  Korte  comprise  1 1  i  cases,  with  i  i  deaths.  In  many 
of  the  cases,  however,  the  fistula  remained.  After  the  removal  of 
the  spur  the  margins  of  the  fistula  were  usually  destroyed  with  the 
actual  cauteiy.  It  will  be  shown  later  that  the  spur  develops  in 
consequence  of  flexion,  and  that  if  the  flexion  is  arrested  in  the 
operative  treatment  of  artificial  anus,  its  removal  is  superfluous. 
The  recent  advances  made  in  intestinal  surgery  will  render  Dupuy- 
tren's  operation  obsolete  in  the  near  future. 

Closure  of  Fistula  by  Plastic  Operation. — The  closure  of  intes- 
tinal fistula.'  b\-  plastic  operation  was  introduced  by  Dieffenbach.  It 
was  not  his  intention,  b\'  the  operation  that  he  devised,  to  close  the 
opening  in  the  bowel  at  once,  but  to  cover  it  with  a  bridge  of  skin, 
leaving  the  closure  to 
be  accomplished  later 
gradually  by  granula- 
tion. Between  two  ellip- 
tic incisions  he  excised 
the  margins  of  the  fistu- 
lous opening  (Fig.  561, 
«)  and  the  skin  sur- 
rounding it.  A  bridge 
of  skin  was  made  by 
making,  on  one  side  of 
the  oval  defect  and  the 
necessar\'  distance  from 
it,  a  curved  incision  twice 
the  length  of  the  wound, 
and,  by  undermining  the 
skin,  mobilizing  a  part 
with  which  to  cover  the 

opening.  The  oval  wound  was  closed  by  interrupted  sutures  (Fig. 
561,  b).  The  operation  leaves  a  crescent-shaped  raw  surface,  pro- 
duced by  sliding  the  bridge,  which  was  left  open  to  heal  by  granu- 
lation. This  operation,  as  well  as  plastic  closure  by  pedunculated 
flaps,  had  its  field  of  u.sefiilness  licfore  alxiominal  operations  were 
rendered  comparatively  safe  by  an  improved  technic  and  the  gen- 
eral adoption  of  a.septic  jjrecautions.  but  is  .seldom,  if  ever,  resorted 
to  at  the  ])re.sent  time. 

Suturing  of  Fistula  without  Opening  the  Peritoneal  Cavity. 
— The  closure  (/  an  intestinal  fistula  In'  vivif\ing  its  margins  and 
suturing,  without  detaching  the  bowel  or  opening  the  peritoneal 
cavity,  has  not  \'ielded  very  satisfactory  results.  The  operation  is 
adapted  only  for  cases  in  which  the  intestine  is  attached  to  the 
abdominal  wall  and  the  fistulous  opening  is  readily  acce.ssible.  and 
where  no  canalization   impediments  are  present.      I  have  succeeded 


Fig.  561. — DieffeiilKiili's  plastic  o])erati()n  for  closure 
of  artificial  anus. 


IOl8  INTESTINAL    FISTULA. 

in  two  cases  in  closing  the  fistula  completely  and  perfectly  by  one 
operation. 

The  first  case  was  a  young  man  eighteen  years  of  age,  who  was  attacked  suddenly 
by  circumscribed  suppurative  peritonitis  in  the  upper  part  of  the  abdominal  cavity.  An 
abscess  formed,  which  was  opened  at  the  left  border  of  the  left  rectus  muscle,  a  little 
below  the  level  of  the  umbilicus.  A  few  days  later  nearly  all  the  intestinal  contents 
escaped  through  the  opening.  The  character  of  the  chyle  that  escaped  indicated  that 
the  intestinal  perforation  was  near  the  stomach.  The  amount  of  intestinal  discharge 
gradually  diminished  in  quantity,  the  patient's  general  condition  improved,  but  the  fistu- 
lous opening  failed  to  close.  When  he  came  under  observation  the  external  opening 
had  contracted  so  that  it  would  admit  only  an  ordinary  grooved  director.  A  long  probe 
could  be  inserted  its  entire  length.  The  patient  was  prepared  carefully  for  the  operation 
by  laxatives  and  careful  dieting.  The  fistulous  tract  was  enlarged  in  an  upward  direc- 
tion, when,  upon  retraction  of  the  margins  of  the  wound,  an  opening  was  found  in  the 
intestine  large  enough  to  admit  the  little  finger.  The  intestine  was  adherent  to  the 
abdominal  wall.  The  whole  fistulous  tract  was  excised,  and  with  it  the  margins  of  the 
opening  in  the  bowel,  without  opening  the  peritoneal  cavity.  After  it  was  ascertained 
that  no  spur  or  other  canalization  difficulties  were  in  the  way  of  a  normal  fecal  circulation, 
the  wound  was  sutured  by  first  bringing  in  accurate  contact  the  mucous  membrane  by  fine 
silk  sutures,  placing  them  close  together.  In  the  next  row  of  buried  sutures  of  catgut 
the  entire  thickness  of  the  bowel- wall  minus  the  mucous  membrane  was  included.  The 
next  row  of  buried  sutures,  of  the  same  material,  included  the  entire  thickness  of  the 
abdominal  muscles,  and  finally  the  skin  was  sutured  separately,  using  for  this  purpose 
fine  silk.  The  antiseptic  dressing  was  retained  by  broad  strips  of  adhesive  plaster. 
Stomach-feeding  was  prohibited  for  three  days.  The  entire  wound  healed  by  primary 
union  under  one  dressing.  The  operation  was  performed  several  years  ago,  and  the 
patient  has  remained  in  perfect  health.  There  can  be  no  doubt  that  in  this  case  the  peri- 
tonitis and  abscess  resulted  from  perforation  of  a  duodenal  ulcer.  The  thickness  of  the 
intestinal  wall,  as  well  as  the  size  of  the  lumen  of  the  bowel,  indicated  that  the  fistula 
occupied  this  part  of  the  intestinal  tract. 

In  the  second  case,  a  man  aged  thirty,  the  fistulous  opening  involved  the  cecum  and 
formed  after  an  attack  of  appendicitis.  The  opening  was  large  enough  to  introduce  two 
fingers,  and  nearly  all  the  intestinal  contents  escaped  through  this  abnormal  outlet. 
Four  or  five  operations  had  been  made,  with  the  result  that  after  each  operation  the  size 
of  the  intestinal  opening  was  increased.  The  patient  was  subjected  to  preparatory  treat- 
ment for  at  least  a  week,  when  a  similar  operation  was  performed  as  in  the  last  case,  with 
the  same  satisfactory  immediate  and  remote  results. 

In  advising  a  resort  to  this,  so  far  as  life  is  concerned,  absolutely 
safe  operation,  it  is  important  to  remember  the  necessity  of  freely 
excising  the  fistulous  tract,  removing  all  the  scar  tissue  and  a  circu- 
lar strip  of  the  mucous  membrane  lining  the  margins  of  the  fistulous 
opening  in  the  bowel,  as  well  as  the  importance  of  bringing  in  accu- 
rate apposition  by  several  tiers  of  buried  sutures  the  different  ana- 
tomic structures.  A  conscientious  observance  of  these  precautions 
will  occasionally  reward  the  surgeon  by  success  in  closing  an  intes- 
tinal fistula  by  extraperitoneal  suturing. 

Intestinal  Anastomosis. — The  formation  of  an  intestinal  anas- 
tomosis in  the  treatment  of  an  intestinal  fistula  is  indicated  in  cases 
in  which  the  extraperitoneal  methods  are  not  applicable  or  have 
proved  unavailing,  and  the  usual  intraperitoneal  operations  are  con- 
traindicated.  Under  such  circumstances  the  exclusion  from  the 
fecal  circulation  of  the  perforated  loop,  by  the  formation  of  an  anas- 
tomotic communication  between  the  afferent  and  efferent  limbs  of 
the  loop,  will  remove  the  annoyances  incident  to  an  intestinal  fistula 
and  place  the  parts  in  a  more  favorable  condition  for  spontaneous 
healing  or  more  successful  surgical  intervention.      The  anastomotic 


ENTERECTOMY.  Iqiq 

opening  should  be  made  at  least  two  inches  in  length.  The  opera- 
tion can  be  performed  most  safely  by  the  use  of  decalcified  perfo- 
rated bone-plates,  the  Murphy  button,  or  by  Czerny-Lembert  sutures. 
For  the  purpose  of  showing  the  value  of  this  method  of  procedure 
in  rare  cases  the  following  observation,  made  a  few  }ears  ago  by 
me,  may  prove  instructive  : 

A  woman  thirty  years  of  age  suffered  for  several  weeks  from  pelvic  peritonitis,  which 
resulted  in  the  formation  of  an  abscess,  which  was  opened  above  Pouparfs  ligament  on 
the  left  side.  A  few  days  after  the  abscess  was  incised  gas  and  fecal  matter  escaped 
from  this  opening.  Additional  abscesses  on  the  same  side  appeared,  which  were  either 
opened  externally  or  discharged  through  the  first  abscess  cavity.  The  fecal  fistula 
remained.  The  case  came  under  my  observation  nearly  a  year  after  the  first  attack.  The 
patient  was  greatly  emaciated  ;  more  than  one-half  of  the  intestinal  contents  escaped 
through  the  abnormal  outlet.  The  fistulous  tract  led  down  into  the  cavity  of  the  pelvis, 
to  the  left  of  the  uterus.  Rectal  insufflation  of  hydrogen  gas  demonstrated  that  the 
fistula  was  above  the  ileocecal  valve.  After  a  few  days  of  preparatory  treatment  the 
abdomen  was  opened,  and  it  was  found  that  the  lower  part  of  the  ileum  was  rolled  up 
into  a  mass  by  numerous  and  firm  adhesions.  A  faithful  attempt  was  made  to  unravel 
the  mass,  but  had  to  be  abandoned,  owing  to  the  extent  and  firmness  of  the  adhesions. 
The  perforated  part  of  the  intestine  could  not  be  found.  The  mass  comprised  from  three 
to  five  feet  of  the  lower  part  of  the  ileum.  Excision  of  this  mass  was  absolutely  out  of 
the  quesdon,  owing  to  the  patient's  general  condition  and  the  number  and  character  of 
the  adhesions.  The  free  intestine  on  the  proximal  side  was  finally  found,  an  anastomotic 
opening  between  it  and  the  sigmoid  flexure  established,  with  the  aid  of  large  decalcified  per- 
forated bone-plates,  and  the  external  incision  closed  by  suturing.  Very  little  fecal  material 
escaped  from  the  fistula  after  the  operation,  while  the  discharges  from  the  bowels  became 
more  copious  and  liquid.  It  was  evident  that  the  fecal  current  had  been  diverted  away 
from  the  numerous  adherent  coils  of  the  lower  part  of  the  ileum  into  the  sigmoid  flexure. 
The  patient  improved  in  general  health  and  was  relieved  from  the  annoyances  incident  to 
an  intestinal  fistula.  A  number  of  times  the  fistulous  opening  closed,  but  reopened  ; 
this  occurrence  was  always  attended  by  a  limited  discharge  of  pus.  The  abscess  cavity 
had  evidently  never  healed  corhpletely,  and  undoubtedly  maintained  the  fistula. 

It  is  to  be  expected  that  the  excluded  part  of  the  intestinal  canal 
will  continue  to  undergo  progressive  atrophy,  and  that  ultimately 
the  fistulous  opening  will  clo.se  spontaneously.  So  far  the  oper- 
ation has  resulted  in  restoring  the  continuit}'  of  the  intestinal  canal 
by  excluding  from  finutional  activity  the  partially  impermeable 
lower  part  of  the  ileum.  It  appears  that  a  .similar  procedure  would 
often  prove  of  great  value  in  the  treatment  of  vesico-inte.stinal  fi.stula 
in  which  the  operative  closure  of  the  opening  and  eiitercctomy  ai"e 
often  found  impracticable. 

Enterectomy. — The  mortality  attending  entercctonn' ami  circu- 
lar enterorrhaphy  in  the  treatment  of  intestinal  fistula  and  artificial 
anus  remains  great  even  in  the  hands  of  experienced  operators. 
The  .stati.stics  of  Reichel  give  a  mortality  of  37.8  per  cent.,  and 
tho.se  of  Hert/.berg,  27  per  cent.  In  view  of  this  fact  it  is  apparent 
that  this  operation  should  be  reserved  for  ca.scs  not  amenable  to 
successful  treatment  by  .safer  procedures.  The  indications  for  this 
operation  can  be  limited  to  exceptional  cases.  If  the  intestine  is  not 
attached  to  the  abdominal  wall,  it  is  much  .safer  to  open  the  free 
peritoneal  cavity  in  .search  of  the  affected  i)art  of  the  intestine  than 
to  follow  the  fistulous  tract  as  a  guide  If  po.ssible,  the  intestine 
.should  be  tied  on  each  side  of  the  fistula  with  a  strip  of  gau/e  or  a 
rubber  band  before  it  is  detached,  in  order  to  guard  more  efficiently 


I020  INTESTINAL    FISTULA. 

against  fecal  extravasation.  The  operation  should  be  performed 
with  the  patient  in  the  Trendelenburg  position,  and  the  peritoneal 
cavity  amply  protected  by  aseptic  compresses  during  the  resection 
and  suturing.  After  the  resection  the  continuity  of  the  bowel 
should  be  restored  by  circular  enterorrhaphy  with  the  Czerny-Lem- 
bert  sutures. 

Preliminary  Transverse  Suturing  of  the  Intestinal  Opening  as 
a  Prophylactic  Measure  Against  Infection  During  the  Operation  for 
Artificial  Anus. — There  can  be  little  doubt  that  the  operative  treat- 
ment of  intestinal  fistula  or  artificial  anus  requiring  opening  of  the 
abdominal  cavity  has  been  attended  by  an  alarming  mortality,  owing 
to  infection  caused  by  the  escape  of  feces  through  the  intestinal 
opening.  Packing  the  opening  with  gauze  or  cotton  is  a  very  in- 
efficient way  to  prevent  fecal  extravasation.  The  use  of  clamps  and 
ligatures  on  each  side  of  the  opening  in  the  bowel  is  equally  un- 
reliable. In  1894  I  proposed  and  practised  successfully  preliminary 
transverse  suturing  of  the  intestinal  opening  as  a  prophylactic  measure 
against  infection.  This  procedure  appears  to  me  as  an  important  safe- 
guard against  this  source  of  danger,  as  by  preliminary  closure  of  the 
intestinal  opening  by  suturing,  placing  the  sutures  so  close  together  as 
absolutely  to  prevent  the  escape  of  any  of  the  intestinal  contents,  a 
prolific  source  of  infection  is  excluded.  After  this  has  been  done 
the  field  of  operation  is  once  more  thoroughly  sterilized  before  the 
abdomen  is  opened  and  the  intestine  detached.  The  sutures  should 
include  all  the  tunics  of  the  bowel.  With  few  exceptions  this  row 
of  sutures  will  remain  as  Czerny  sutures,  to  be  buried,  after  the 
bowel  has  been  detached,  by  Lembert  stitches.  The  statement  has 
already  been  made  that  flexion  of  the  bowel  is  the  most  important 
factor  in  producing  the  spur,  and  that  measures  that  are  calculated 
to  correct  the  flexion  will  prove  useful  in  removing  the  spur.  In 
artificial  anus,  produced  accidentally  or  intentionally,  the  flexion  is 
caused  by  the  prolapse  of  the  intestinal  loop  into,  and  sometimes 
even  beyond,  the  opening  in  the  abdominal  wall.  If  the  intestine  is 
detached,  the  flexion  is  diminished  or  completely  corrected,  and  its 
recurrence  is  prevented  by  transverse  suturing  of  the  intestinal 
opening.  The  correctness  of  these  statements  is  apparent,  and  can 
be  corroborated  by  the  report  of  two  cases  of  artificial  anus  which 
were  operated  upon  in  the  clinic  of  Rush  Medical  College  : 

The  first  patient  was  a  man  twenty-nine  years  of  age,  an  Irish-American.  About  a 
year  before  he  entered  the  Presbyterian  Hospital  he  was  taken  suddenly  ill  with  severe 
pain  in  the  right  iliac  fossa.  The  attending  physician  made  a  diagnosis  of  appendicitis, 
and  four  days  later  opened  an  abscess  at  a  point  about  two  inches  from  the  inner  side 
of  the  anterior  superior  spinous  process  of  the  ilium.  A  few  days  later  feces  escaped 
through  the  opening.  An  attempt  was  made  to  prevent  the  escape  of  fecal  matter  by 
applying  a  compress.  Then  followed  twelve  operations,  with  the  intention  of  closing  the 
fistula,  in  one  of  the  hospitals  in  St.  Louis.  The  only  result  effected  by  the  operations  was 
increased  size  of  the  opening.  When  the  case  was  presented  in  the  clinic  of  Rush  Medical 
College,  the  opening  in  the  abdominal  wall  and  the  anterior  wall  of  the  cecum  was  large 
enough  to  insert  three  fingers.  In  the  center  of  the  opening  was  found  a  well-developed  spur 
that  effectually  prevented  the  entrance  of  any  of  the  intestinal  contents  into  the  colon.  The 
border  of  the  opening  in  the  abdominal  wall  was  lined  by  the  ectropic  mucous  membrane  of 


OPERATION    FOR    ARTIFICIAL    ANLS.  io2I 

the  cecum  (Fig.  562).      The  ileocecal  valve  could  be  seen  and  felt  below  the  ^n„.-      T, 
patient  was  prepared  for  the  operation  by  dieting,  laxatives,  and  a  daii;\^   nXih  for  t 
week.       The  operation  was  commenced  by  suturing  the  oblonij  vertical  in7e.i,  , 
transverse  y,  using  for  this  purpose  hue  sk  and  fn  ordina^sewig  need    "^^^^^^ 

sistedu.  includmg  in   two  elliptic^inLion^^rta,^:;:  orriEd^^tr^;;:;- l),-^^ 


Fig.  562.— Artificial  anus  following  appendicitis.      Well-marked  ectropion  of  the  nuico 

membrane. 


J''K-  5^3- — Provisional  sutures,  including  all  the  tunirsof  the  bowel.    Transverse  sntiiiiiig 

of  intestinal  oi)eniiig. 


the  scar  tissue  in  its  vicinity,  '{'he  peritoneal  cavity  was  ()|)ciie(l  by  a  slrnighl  incision  «-x- 
fending  downward  from  the  lower  angle  of  the  two  incisions.  The  bowel  was  dclnchrd 
from  the  abdominal  wall  and  drawn  forward  into  the  external  iii(isi<in.  The  strip  of  .skin 
and  scar  tissue  were  carefully  trinuned  away  from  the  bowel  with  .scissors,  when  the  pro 
visional  sutures  were  buriefl  by  a  row  of  I.embert  stitches  (Fig.  564). 

The  prolapserl  |jart  of  the  bowel  was  cleansed,  thicd,  and  rc|)Iacc<l  in  the  abdominal 
cavity,  and  the  external  wound  closed  by  four  tiers  of  sutures  (Fig.  S^'S)-     "'•-■  "''""' 


I022 


INTESTINAL    FISTULA. 


antiseptic  dressing  was  applied  and  confined  in  place  by  broad  strips  of  adhesive  plaster. 
Not  a  single  untoward  symptom  followed  the  operation.  The  wound  healed  throughout 
by  primary  intention.  The  bowels  responded  to  a  laxative  on  the  third  day,  and  subse- 
quently moved  daily  without  further  assistance.  The  patient  left  the  hospital  at  the  end 
of  four  weeks,  with  instructions  to  wear  a  pad  for  at  least  six  months. 

The  second  case  was  a  girl  nine  years  of  age.  During  October,  1893,  she  suffered 
from  an  acute  attack  of  appendicitis  which  resulted  in  the  formation  of  a  large  abscess. 
The  abdomen  was  opened  and  the  perforated  appendix  removed.      It  was  noticed  that 


Fig.  564. — Intestine  detached  and  drawn  forward  into  wound.     Provisional  sutures 
buried  by  a  row  of  Lembert  stitches. 


Fig.  565. — Operation  completed. 

the  anterior  wall  of  the  cecum  presented  a  large  gangrenous  patch.  It  was  deemed 
advisable  to  anticipate  perforation  by  excluding  this  area  from  the  free  peritoneal. cavity 
by  a  ring  of  sutures,  uniting  the  visceral  with  the  parietal  peritoneum.  The  remainder 
of  the  incision  was  closed  with  the  exception  of  a  space  for  drainage.  The  patient's 
general  condition  improved  promptly  after  the  operation.  The  gangrenous  part  sloughed 
away,  leaving  a  large  opening  in  the  cecum.  Through  this  opening  nearly  all  the  intes- 
tinal contents  escaped,  as  an  efficient  spur  formed  at  the  middle  of  the  opening.  The 
contact  of  feces  with  the  skin  produced  in  this  case  an  intense  and  diffuse  dermatitis. 
When  the  patient  entered  the  Presbyterian  Hospital  in  January,   1894,   the  dermatitis 


OPERATIVE  TREATMENT.  IO23 

involved  more  than  one-half  of  the  anterior  surface  of  the  abdomen.  The  treatment  t)f 
this  affection  proved  very  tedious,  so  that  two  months  later,  when  the  operation  was  per- 
formed before  the  class  of  Rush  Medical  College,  a  patch  of  skin  the  size  of  the  palm 
of  the  hand  still  remained  in  a  state  of  intense  irritation. 

The  same  operation  was  performed  as  on  the  preceding  patient,  with  similar 
satisfactor)-  immediate  and  remote  results.  Instead  of  constipation,  the  operation  was 
followed  by  diarrhea,  which  continued  for  several  days,  provoked  probably  by  bringing 
the  intestinal  contents  in  contact  with  the  colon,  which  had  been  almost  completely 
excluded  from  the  fecal  circulation  for  five  months.  The  wound  healed  by  primary  inten- 
tion throughout.  The  dermatitis  disappeared  promptly  after  the  removal  of  the  cause. 
The  patient  left  the  hospital  in  perfect  health  four  weeks  after  the  operation. 

A  third  case  was  the  subject  of  a  large  intestinal  fistula  high  up 
in  the  intestinal  canal. 

The  patient  was  a  female  fifty  years  of  age,  who  was  operated  ujxm  for  intestinal 
obstrucdon  a  number  of  months  before  she  came  under  my  care.  The  symptoms  of 
obstruction  abated  after  the  operation,  but  the  fistula  remained.  An  hour  after  eating 
nearly  all  the  half-digested  food  escaped  through  the  fistulous  opening  that  was  found  to 
the  left  of  the  median  line  and  above  the  level  of  the  umbilicus.  The  opening  was  large 
enough  to  admit  two  fingers.  The  patient  was  emaciated  to  a  skeleton.  The  perme- 
ability of  the  intestinal  canal  below  the  fistula  was  established  by  rectal  insufflation  of  air. 
The  opening  in  the  bowel  was  sutured  transversely,  after  which  the  field  of  operation  was 
again  disinfected,  when  the  abdominal  cavity  was  opened  and  the  adherent  intestinal 
loop  detached.  The  adhesions  were  found  so  extensive  that  the  peritoneum  was  not 
within  reach  of  the  Lembert  sutures.  After  burying  the  provisional  sutures  with  a  row 
of  fine  silk  sutures  that  included  the  entire  thickness  of  the  intestinal  wall  minus  the 
rauco.sa,  the  omentum  was  stitched  over  the  line  of  suturing,  and  the  omental  flap  was 
made  to  include  the  whole  denuded  surface  of  the  intestine.  The  intestinal  loop  was 
returned  and  the  incision  completely  closed.  The  wound  healed  by  primary  intention 
throughout,  and  normal  bowel  function  was  restored  by  the  operation.  The  patient  left 
the  hospital  four  weeks  after  the  operation  and  has  remained  in  excellent  health  since. 

A  study  of  these  cases  is  well  calculated  to  prove  that  the  pro- 
vi.sional  closure  of  the  intestinal  opening  by  transverse  suturing 
before  using  the  knife  is  the  most  efficient  prophylactic  measure 
against  infection,  and  also  to  show  that  resection  of  the  intestine  for 
fistula  and  artificial  anus  can  be  avoided  in  the  majority  of  cases,  and 
that  in  its  place  transverse  suturing  and  correction  of  the  flexion  will 
yield  better  results. 


CHAPTER  XXVIII. 

RESECTION  OF  JOINTS. 

In  a  treatise  on  emergency  surgery  we  should  not  expect  to  find 
resection  of  joints  discussed  in  detail.  Primary  resection  for  joint 
injuries  has  become  the  exception,  rather  than  the  rule.  Before 
aseptic  surgery  was  known,  penetrating  wounds  of  the  joints  were 
considered,  for  good  reasons,  formidable  and  dangerous  injuries. 
The  fearful  mortality  that  attended  gunshot  wounds  of  the  large 
joints  during  the  Civil  War  led  surgeons  to  resort  either  to  ampu- 
tation or  to  typical  resection,  with  the  hope  of  diminishing  the 
immediate  risks  to  life.  There  can  be  no  question  but  that  these 
attempts  were  instrumental  in  diminishing  the  mortality,  but  the 
results  thus  achieved  were  dearly  bought.  Fortunately,  asepsis  has 
introduced  a  new  era  in  the  treatment  of  open  injuries  of  joints. 
Compound  fractures  involving  joints  and  gunshot  injuries  have  lost 
their  terror  since  ample  experience  has  demonstrated  that  a  timely 
first-aid  dressing,  under  strictest  aseptic  precautions,  suffices,  as  a 
rule,  in  protecting  the  patients  against  wound  infection  and  its 
manifold  complications.  In  another  part  of  this  work  it  has  been 
shown  that  these  injuries  are  amenable  to  successful  conservative 
treatment,  provided  they  are  subjected  to  rational  modern  surgical 
treatment  before  the  wound  has  become  infected.  It  may  be  stated, 
as  a  rule  to  which  there  are  few,  if  any,  exceptions,  that  primary 
resection  for  recent  joint  injuries  has  been  relegated  to  the  past, 
and  that  the  surgeons  of  the  present  concentrate  all  their  energies 
in  protecting  the  wound  against  infection.  In  gunshot  wounds  the 
first-aid  dressing  is  relied  upon,  and  it  must  be  considered  not  only 
unsurgical,  but  almost  criminal,  to  ascertain  by  probing  or  other- 
wise the  extent  of  the  joint  injury.  Joints  that  have  been  pene- 
trated by  a  bullet,  causing  extensive  comminution  of  the  articular 
ends,  will  recover  if  the  wound  remains  aseptic,  and  very  often  the 
conservative  effort  is  rewarded  by  a  good,  if  not  a  perfect,  range 
of  motion.  In  compound  fractures  with  extensive  comminution 
but  a  small  opening  in  the  skin,  the  same  conservative  treatment 
will  often  yield  similar  favorable  results.  If  the  wound  is  large, 
and  especially  if  it  has  been  inflicted  by  direct  force,  exploration 
under  the  most  pedantic  aseptic  precautions  not  only  is  justifiable, 
but  also  absolutely  necessary.  The  finger  and  instruments  used  in 
making  the  intra-articular  examination  must  be  made  faultlessly 
aseptic.  The  surface  of  the  wound  and  the  adjacent  skin  over  a 
liberal  area  must  be  disinfected  thoroughly  before  the  examination 
is  made.      Fragments  of  bone  completely  detached  should  be  re- 

1024 


INDICATIONS.  jQT- 


moved.  and  m  cases  in  which  one  of  the  articular  extremities  has 
been  extensively  destrojed,  an  atypical  resection  may  become  nec- 
essar>',  not  for  the  purpose  of  diminishing  the  risks  of  infection  but 
with  the  intention  of  leaving  the  injured  joint  in  the  best  possible 
condition  for  repair  and  for  securing  a  maximum  functional  result 

From  the  foregoing  remarks  it  will  be  seen  that  modern  surgery 
does  not  tolerate  typical  resection  for  recent  injuries,  and  that  atypi- 
cal or  incomplete  resection  is  reserved  for  exceptional  cases  when 
the  extent  of  destruction  of  one  or  both  of  the  articular  extremities 
warrants  such  a  procedure.  Acute  suppurative  inflammation  of  the 
large  joints,  so  frequently  subjected  in  the  past  to  amputation  and 
resection  as  life-saving  measures,  furnishes  no  longer  an  excuse  to 
the  surgeon  to  perform  a  mutilating  operation.  Free  incision,  thor- 
ough drainage,  immobilization  of  the  joint,  antiseptic  flushings  or 
continuous  irrigation  with  a  mild  anti.septic  solution,  have  taken  the 
place  of  amputation  and  resection,  and  the  results,  so  far  as  both 
life  and  limb  are  concerned,  have  been  vastly  improved  by  the 
change  from  mutilating  to  conservative  surgery-.  A  resection  mav 
occasionally  become  necessary  after  the  acute  symptoms  have  sub- 
sided in  cases  in  which  the  articular  ends  have  been  extensively 
destroyed,  and  in  which  the  suppuration  does  not  yield  to  the  intra- 
articular anti.septic  treatment. 

It  is  not  more  than  ten  \ears  since  typical  resection  of  joints  for 
tuberculosis  appeared  to  be  not  only  a  justifiable,  but  also  an  estab- 
lished, surgical  procedure.  A  visitor  to  any  of  the  large  clinics 
could  see  one  or  more  resections  of  the  large  joints  daily.  To-day 
the  operation  is  looked  upon  with  suspicion,  as  an  enormous  statis- 
tic material  has  shown  that,  with  some  exceptions,  the  conservative 
treatment  by  iodoform  injections  and  rest  gives  better  functional 
results,  and  that  the  operation  has  very  little,  if  any,  more  influence 
in  preventing  reinfection.  In  synovial  tuberculosis  that  proves  rebel- 
lious to  the  con.ser\ati\e  treatment,  excision  of  the  diseased  capsule 
meets  the  j^athologic  indications,  and  few,  if  any,  surgeons  of  to-day 
would  be  willing  to  substitute  a  complete  resection  for  arthrcctomy 
in  such  cases.  In  primary  os.seous  tuberculosis  with  involvement  of 
the  joint  typical  resection  still  holds  a  creditable  place  in  the  fielil 
of  operative  surger)'.  Hut  even  in  such  instances  the  tendency  of 
the  present  teaching  anfl  practice  is  to  use  .saw  and  chi.sel  as  spar- 
ingly as  possible,  and  limit  the  operative  treatment  to  the  removal 
of  diseased  tissue.  Arthrectomy  and  aty[)ical  resection  have  drawn 
the  legitimate  indications  for  complete  resection  to  within  very  nar- 
row limits,  and  the  restrictions  for  the  operation  will  Ixronu-  more 
rigid  with  the  incrca.se  of  our  knowledge  pertaining  to  the  nature 
and  intrinsic  tendencies  of  the  tubercular  affections  of  joints. 

There  are  three  indications  of  modern  date  that  have  opened  up 
new  fields  for  resection — unknown  and  d.ingerous  ground  berf)re 
aseptic  surgery  made  it  possible  to  deal  .safely  with  open  wounds 
of  joints.      These  new  indications  are  : 


I026  RESECTION    OF   JOINTS. 

1.  Irreducible  dislocations  of  joints. 

2.  Angular  ankylosis  that  renders  the  limb  practically  useless. 

3.  Fixation  of  joints  of  paralytic  limbs  (arthrodesis),  to  render 
the  limb  useful  by  effecting  an  ankylosis. 

These  are  all  operations  for  aseptic  conditions,  and  should  be 
undertaken  only  by  surgeons  well  grounded  and  experienced  in 
aseptic  work,  and  who  have  at  their  command  all  the  appliances 
and  facilities  for  securing  perfect  asepsis.  The  operative  treatment 
of  such  cases  is  attended  by  great  responsibility  on  the  part  of  the 
surgeon,  and  every  precaution  must  be  practised  to  prevent  infec- 
tion. Ample  time  and  the  most  pedantic  preparations  are  necessary 
to  render  the  limb  to  be  operated  upon  aseptic.  Haste  and  inade- 
quate preparation  are  inexcusable,  as  the  result  of  the  operation  will 
largely  be  determined  by  the  thoroughness  and  care  with  which  the 
preparations  were  made. 

The  operation  of  excision  of  the  soft  tissues  of  the  joint,  synovial 
membrane,  and  capsule  is  called  artlirectoviy  (Volkmann).  Extirpa- 
tion of  the  diseased  synovial  membrane  is  known  as  synovectomy. 
The  proper  designation  of  the  operation  of  excision  of  the  synovial 
membrane  and  the  articular  ends  of  the  joint  is  arthrcctomia  syn- 
ovialis  et  ossis.  Removal  of  the  diseased  s}movial  membrane  by 
scraping  with  a  sharp  spoon  has  been  known  as  evasion.  A  typical 
resection  consists  in  the  excision  of  both  articular  surfaces  of  the 
bones,  and  by  an  atypical  resection  is  understood  the  removal  of 
only  the  diseased  portion  of  the  joint,  or  the  excision  of  a  part  of 
the  joint  for  injury  or  disease,  with  a  view  to  improving  the  local 
conditions  for  a  more  satisfactory  repair  of  the  injury  and  a  better 
functional  result.  In  performing  a  resection  of  a  joint  for  disease  it 
is  necessary  to  expose  the  cavity  of  the  joint  freely  for  the  purpose 
of  ascertaining  the  location  and  extent  of  the  disease  and  to  bring 
the  tissues  to  be  removed  within  easy  reach  of  the  instruments.  In 
resection  for  tuberculosis,  for  instance,  the  diseased  soft  structures 
of  the  joint  must  be  removed  with  the  same  thoroughness  as  in 
operations  for  malignant  disease  ;  osseous  foci  must  be  discovered, 
and  when  found,  removed  by  a  vigorous  use  of  the  sharp  spoon, 
chisel,  or  saw,  according  to  the  extent  and  location  of  the  disease. 
In  the  resection  of  a  joint  the  external  incision  must  be  made  with 
special  reference  to  affording  free  access  to  the  joint  and  guarding 
against  accidental  injury  to  any  of  the  important  structures  around 
the  joint.  Vessels,  muscles,  tendons,  and  nerves  are  to  be  carefully 
protected,  and  the  periosteum  is  preserved  as  far  as  it  is  free  from 
disease,  as  is  also  the  capsule.  Muscular  and  tendinous  insertions 
must  be  interfered  with  as  little  as  possible,  and  bony  prominences 
of  the  articular  extremities,  when  not  the  seat  of  disease,  must  be 
■  carefully  preserved.  Temporary  resection  of  bony  prominences  to 
which  important  muscles  and  tendons  are  attached  has  become  an 
important  feature  of  the  modern  technic  of  resection,  particidarly  in 
cases  in  which  it  is  reasonable  to  e?ztertain  the  hope  that  the  patient 


OPERATIVE    METHODS. 


1027 


will  rccoi'cr  ivith  a  useful  joint ;  this  is  often  the  case  after  ar three  to- 
my,  and  occasionally  after  an  atypical  resection. 

Filing  made  a  great  advance  in  the  technic  of  resection  of  joints 
when  he  advocated  the  advisability  and  utility  of  temporary  resec- 
tion of  the  more  important  bony  prominences  of  the  articular 
extremities,  such  as  the  trochanter  major,  olecranon,  and  the 
malleoli.  These  bony  prominences,  even  in  cases  of  far-advanced 
joint  tuberculosis,  are  seldom  the  seat  of  disease  to  any  extent,  and 
should  therefore  not  be  included  in  the  resection.  All  these 
prominences  serve  as  points  of  attachment  of  important  muscles, 
and  if  sacrificed,  it  is  difficult,  and  more  often  impossible,  to  furnish 
the  detached  muscle  or  tendon  with  a  new  point  of  anchorage  with 
the  same  mechanical  advantages.  Temporary  resection  of  all  these 
prominences  secures  free  access  to  the  respective  joints,  and  after 
the  arthrectomy  or  resection  has  been  completed,  the  tletachcd 
fragment  of  bone  is  replaced  in  its  former  position  and  held  in  place 
by  direct  means  of  fixation.  Aseptic  bone  or  ivory  nails,  silver  wire, 
and  catgut  are  the  materials  most  frequently  relied  upon  in  retain- 
ing the  fragment  in  position  until  it  has  united  by  bony  callus  with 
the  shaft  of  the  bone.  My  experience  with  temporary  resection  of 
the  olecranon,  trochanter  major,  malleoli,  and  the  patella  has  been 
of  the  most  satisfactory  kind,  and  it  is  my  opinion,  based  on  a  large 
clinical  experience,  that  if  the  fragment  is  properly  replaced  and 
immobilized  b)'  nailing  or  suturing,  bony  union  akvays  takes  place  in 
the  Jisnal  time,  provided  the  wound  remains  aseptic.  After  temporai-y 
resection  of  the  patella  by  transverse  section  I  have  always  resorted 
to  catgut  sutures  in  bringing  and  holding  the  fragments  in  contact, 
and  if  the  wound  remained  aseptic,  bony  union  invariably  has  been 
observed  three  or  four  weeks  after  the  operation.  A  mattress  suture 
of  coarse  catgut,  aided  by  two  lateral  sutures,  can  be  relied  upon  in 
keeping  the  fragments  in  accurate  contact.  Temporary  resection  of 
the  olecranon  process  is  made  with  the  saw  or  chisel,  making  the 
section  obliquely  from  the  ulna  through  the  ba.se  of  the  process, 
so  that  the  ulnar  fragment  represents  a  wedge  with  the  base  on  the 
.side  of  the  olecranon.  The  trochanter  major  is  removed  in  a  similar 
manner.  In  both  instances  fixation  b\-  a  bone  or  ivor)-  nail  can  be 
relied  upon  in  holding  the  fragment  in  proper  position  un'til  it  has 
again  become  a  part  of  the  shaft  of  the  bone  by  bony  consolidation. 
The  malleoli  are  free  from  any  muscular  attachments,  and,  after 
temporary  resection,  are  securely  immobilized  by  one  or  two  catgut 
sutures  pas.sed  through  the  periosteum  and  paraperiosteal  tissues  of 
the  bone  on  both  sides.  The.se  proces.scs  are  detached  at  their  base 
with  the  chisel  by  a  straight  cut,  hence  the  fracture  is  a  transverse 
one  and  is  immobilized  by  the  catgut  sutures  for  a  sufficient  length 
of  time  for  bony  luiion  to  take  j>lace. 

The  preservation  of  muscular  attachments  by  teniporary  rc.scc- 
tion  of  the  os.seous  points  of  insertion  and  origin  has  a  promi.sing 
future,  and  should  be  resorted  to  in  all  cases  in  which  i'"-  in.is.lcs. 


I028 


RESECTION    OF    JOINTS. 


Fig.  566. — Bone-holding  forceps  :  a,   Langenbeclc' s  ;  I/,   Fergusson's;  c,  Faraboeuf's. 


Fig-  567- — Bone-cutting  forceps  :  A,   Liston's;   B,   Liston's  curved  on  the  flat  ;   C,   Sat- 
terlee's  cross  cutting;  D,  Velpeau's  cross  cutting. 


INSTRUMENTS. 


1029 


Fig.  568. — Langenbeck's  narrow  saw. 


^'g-  569- — Lifling-back  metacarpal  saw. 


Fig-  570 — Macewen's  chisel. 


F'g-  57'- — ^  o'l  '5riins'  chisel. 


Fig.  572. — Gouge  for  use  with  liaiul  or  cliibel. 


Fig.  573. — Macewen'.s  gouges. 


M^.  ^75. — \<>ii  liniiis'  s|)'H. 


I030 


RESECTION    OF   JOINTS. 


tendons,  and  bone  are  free  from  disease,  and  in  which  restoration  of 
motion  can  be  expected. 

The  most  important  instruments  used  in  making  a  resection  of 
a  large  joint  are  a  short  stout  scalpel,  periosteal  elevator,  Truax's 
or  Butcher's  saw,  a  metacarpal  saw,  chain  saw,  bone-cutting  forceps, 
strong  grasping  forceps,  chisel  and  hammer,  Cooper's  scissors,  dis- 
secting forceps,  and  broad,  sharp-toothed  retractors.  The  necessary 
fixation  material  to  be  used  after  temporary  resection  of  any  portion 
of  the  articular  ends  must  be  at  hand  and  ready  for  use,  as  well  as 
splints  or  plaster-of-Paris  for  immobilization  of  the  limb.  The 
chain  saw,  so  frequently  in  use  but  a  few  years  ago,  is  seldom  seen 
in  the  operating  room  at  the  present  time,  as  its  place  has  been 
largely  taken  by  the  chisel  in  cases  in  which  the  ordinary  resection 
saw  can  not  be  used. 


Fig.  576. — Treves'  douche  spoon. 


Fig.  577. — Chain  saw. 


General  Directions  for  Joint  Resection. — The  incisions  for 
resection  of  the  different  joints  are  made  parallel  to  the  important 
soft  structures  that  surround  the  joint,  and  in  places  in  which  they 
are  least  likely  to  be  exposed  to  unintentional  injury.  The  principal 
blood-vessels,  nerves,  muscles,  and  tendons  must  be  avoided.  The 
surgeon  must  be  familiar  with  the  anatomy  of  the  joint  and  its  sur- 
roundings to  enable  him  to  plan  the  different  operations  upon  an 
anatomic  basis,  and  to  perform  them  with  safety  to  the  important 
structures  at  the  site  of  operation.  This  part  of  the  technic  of 
resection  has  undergone  radical  changes  for  the  better  during  the 
last  two  decades.  Many  new  incisions  have  been  devised,  with  spe- 
cial reference  to  the  anatomy  of  the  tissues  at  the  seat  of  operation, 
and  with  the  intention  of  exposing  the  interior  of  the  injured  or 
diseased  joint  freely  to  the  eye  and  touch,  to  facilitate  the  removal 
of  fragments  of  detached  bone,  foreign  bodies,  and  the  diseased 
articular  structures.      The  joints  of  the  fingers  and  the  metatarso- 


GENERAL    DIRECTIONS    FOR   JOINT    RESECTION.  IQt^i 

phalangeal  joints,  the  ankle-  and  the  hip-joint,  are  usually  resected 
through  a  lateral  incision  ;  the  arm-  and  the  elbow-joint,  throuo-h  a 
dorsal  incision.  The  knee-joint  is  reached  most  readiU'  and  with 
least  risk  to  important  structures  through  an  anterior  incision,  and 
the  shoulder-joint  is  most  freely  exposed  by  temporary  resection  of 
the  acromion  process  and  formation  of  a  deltoid  flap.  As  a  rule, 
the  incision  is  made  where  the  joint  is  nearest  the  surface  of  the  skin 
and  where  the  important  soft  tissues  are  at  a  safe  distance  from  the 
proposed  line  of  incision  or  where  they  can  be  readily  displaced 
during  the  operation.  If  a  vertical  incision  does  not  furnish  the 
required  space,  it  is  often  pricked  by  a  lateral  cut,  or  the  incision  is 
made  curved  or  semilunar,  as  is  done  in  resection  of  the  hip-  and 
the  knee-joint.  After  the  first  incision  has  been  made,  the  knife  is 
used  as  sparingly  as  possible,  and  must  largely  give  place  to  the 
periosteal  elevator. 

In  freeing  the  articular  ends,  the  knife  and  periosteal  elevator 
must  hug  the  bone  closely,  for  two  reasons — first,  to  avoid  injuring 
unintentionally  important  para-articular  structures  ;  second,  to  pre- 
serve as  much  as  possible  of  the  healthy  tissues.  Especial  care 
must  be  exercised  in  arthrectomy  and  atypical  resection,  as  it  is  in 
such  instances  that  partial  restoration  of  joint  motion  may  be  ex- 
pected, tiie  functional  result  depending  largely  on  the  care  exercised 
in  the  preservation  of  the  soft  structures  concerned  in  joint  motion. 
The  importance  of  subperiosteal  resection  of  joints  was  emphasized 
strongly  by  Oilier,  von  Langenbeck,  and  von  Volkmann.  The 
capsule  of  the  joint  is  always  opened  freely,  and  if  found  healthy, 
it  is  carefully  preserved  with  the  periosteum.  Capsule  and  perios- 
teum must  be  detached  and  reflected  with  the  overlying  tissues. 
It  is  in  this  step  of  the  operation  that  the  resection  knife  is  indis- 
pensable, as  the  ligaments  can  not  be  detached  with  the  peiiosteal 
elevator.  With  short  cuts,  with  the  knife  directed  toward  the  bone, 
the  capsule  is  detached,  when  the  periosteum  is  separated  with  the 
raspatory  or  a  narrow  straight  chi.sel  or  gouge.  Tearing  and  con- 
tusion of  the  periosteum  are  to  be  carefully  avoided.  Vogt  long 
ago  advocated  the  advisability  of  chiseWng  away  the  compacta  of 
the  bone,  with  the  muscle  or  tendcjn  insertion,  from  the  articular 
extremities  at  points  where  important  muscles  and  tendons  are 
attached.  In  a  complete  resection  of  a  joint  the  articular  extremi- 
ties are  denuded  of  all  .soft  structures,  and  turned  out  of  the  wound 
sufficiently  to  permit  their  removal  with  the  .saw.  In  chiUiren  the 
epiphyseal  cartilage  must  be  preserved,  if  this  can  be  done  with  the 
complete  elimination  of  the  di.seased  tissues,  as  the  less  of  this  im- 
portant bone-producing  center  invariably  results  in  great  shortening 
of  the  limb.  A  .small  .saw,  used  by  mechanics,  does  excellent 
.service  in  exci.sing  the  articular  ends,  as  with  this  instrument  the 
section  can  be  made  in  all  po.ssible  shapes—straight,  curved,  or 
angular.  If  one  or  both  of  the  articular  en<ls  are  loose  in  tlir 
joint  in  consequence  of  injury  or  di.sease,  they  are  removed  with   a 


1032  RESECTION    OF    JOINTS. 

sequestrum  forceps.  Small  loose  fragments  are  extracted  with  dis- 
secting or  hemostatic  forceps.  As  restoration  of  motion  of  the 
joint  is  more  hkely  to  occur  if  only  one  of  the  articular  surfaces  is 
removed,  partial  or  atypical  resection  should  always  take  the  place 
of  complete  resection  whenever  such  a  course  is  compatible  with 
the  extent  of  the  injury  or  disease  for  which  the  operation  is  per- 
formed. If  the  nature  of  the  disease  is  of  such  a  character  that  sub- 
sequent use  of  the  joint  would  tend  to  bring  about  a  relapse,  com- 
plete resection  is  made,  with  the  intention  of  obtaining  a  bony  union 
between  the  two  resected  ends.  It  is  in  instances  of  this  kind  that 
the  surgeon  often  imitates  the  work  of  the  mechanic  and  resects 
the  articular  ends  in  such  a  manner  that  the  bone  surfaces  support 
each  other,  a  great  advantage  in  the  subsequent  immobilization  of 
the  seat  of  resection. 

Elastic  constriction  is  now  invariably  employed  in  resection,  as 
well  as  amputation,  as  it  not  only  serves  in  preventing  unnecessary 
loss  of  blood  during  the  operation,  but  is  also  of  the  greatest  ser- 
vice in  rendering  the  seat  of  operation  bloodless,  giving  the  surgeon 
a  better  opportunity  to  ascertain,  by  inspection  of  the  bloodless 
tissues,  the  extent  of  the  injury  or  disease.  In  resection  of  the  hip- 
joint  elastic  constriction  is  inapplicable,  and  the  operator  has  to  rely 
on  the  hemostatic  forceps  in  controlling  the  hemorrhage  during  the 
operation.  For  some  time  it  was  customary,  after  resection  of  the 
knee-joint,  to  complete  the  operation  before  removing  the  elastic 
constrictor  (Neuber).  This  practice  did  not  survive  the  test  of 
experience,  as  the  hemorrhage  after  the  removal  of  the  constrictor 
was  often  sufficiently  copious  to  require  reopening  of  the  wound  and 
ligation  of  the  bleeding  vessels  ;  if  it  were  not  sufficiently  profuse  to 
demand  such  interference,  it  always  interfered  with  an  ideal  speedy 
healing  of  the  resection  wound.  After  the  7^esection  lias  beeii  made, 
the  elastic  constrictor  should  be  removed  and  hemorrhage  careftdly 
arrested  by  ligature,  tendon,  and  surface  compression,  before  the  zvound 
is  sutured ;  saline  solution  should  not  be  used.  The  bleeding  from 
the  bone  is  often  quite  profuse,  and  frequently  surface  compression 
has  to  be  continued  for  some  time  until  it  is  under  control,  but  the 
wound  nmst  remain  open  until  it  is  dry. 

Steel,  ivory,  and  bone  nails  for  fixation  of  the  resected  ends,  so 
much  relied  upon  in  the  past,  can  akvays  be  dispensed  with,  as 
immobilization  by  an  external  mechanical  support  can  be  relied 
upon  in  maintaining  apposition  between  the  resected  ends,  if  this  is 
what  the  surgeon  desires,  and  in  securing  rest  for  the  hmb. 

Atrophy  of  the  limb  in  consequence  of  the  disease  for  which  the 
operation  was  performed,  and  as  the  result  of  prolonged  rest,  often 
reaches  a  high  degree,  but  the  subsequent  use  of  the  limb,  aided  by 
massage  and  electricity,  will  accomplish  much  in  improving  the 
nutrition  and  function  of  the  muscles.  The  atrophy  not  only  affects 
the  muscles,  but  also  all  the  tissues  of  the  limb,  and  more  particu- 
larly the  bones.      Great  mistakes   have  been   made  in  practice  by 


RESECTION    OF    SPECIAL    JOINTS.  IO33 

surgeons  who  are  not  sufficiently  familiar  with  the  marked  atrophy 
of  the  bones  in  long-standing  joint  disease.  The  osteoporosis  of 
the  articular  ends  not  infrequently  reaches  such  a  degree  of  soften- 
ing that  the  bone  can  be  cut  with  the  knife,  and  yet  the  bone  is  not 
diseased,  but  o)dy  atropine  to  a  high  degree.  In  performing  a  resee- 
tion  a  sharp  distinction  must  be  made  between  atrophic,  softened,  and 
diseased  bone,  else  the  surgeon  is  liable  to  cany  the  resection  beyond 
the  reqmred  limits,  or,  perchance,  discouraged  by  the  appearance  of  the 
softened  bone,  may  deem  it  necessary  to  abatidon  the  intended  resection 
and  sacrifice  the  limb  by  an  unnecessary  amputation.  If  after  a 
complete  resection,  it  is  the  object  of  the  operation  to  obtain  union 
betti'cen  the  resected  ends  by  bony  ankylosis,  the  limb  must  be  placed 
and  immobilized  in  the  most  useful  position  and  treated  as  a  fracture. 

In  resection  of  the  knee-joint  the  bone  sections  are  made  in  such 
a  manner  that  the  surfaces  of  the  resected  ends  come  in  contact  with 
the  leg  slightly  flexed,  as  the  patient  walks  better  and  more  grace- 
fully with  the  limb  in  thi.s  than  in  a  straight  position.  The  arm  at 
a  right  angle  is  more  u.seful  tlian  a  straight  arm.  In  cases  in  which 
it  is  probable  that  joint  motion  can  be  restored,  efforts  in  this  direc- 
tion by  active  and  passive  motion  are  made  as  soon  as  the  operation 
wound  has  healed.  In  mobilizing  large  joints  after  incomplete  t)r 
complete  resections,  earl\-  pas.sive  motion  may  necessitate  the  ad- 
ministration of  an  anesthetic  at  interval.s  of  a  week  or  two,  until  the 
pain  incident  to  such  movements  has  been  diminished  sufficiently 
for  the  patient  to  pass  through  such  ordeals  without  an  anesthetic. 
Systematic  massage  and  the  rational  employment  of  electricity  will 
do  much  to  restore  muscle  function,  nutrition,  and  joint  motion. 

Resection  of  Special  Joints. — The  general  rules  that  have  been 
laid  down  to  guide  the  surgeon  in  his  operative  work  on  joints  must 
be  variously  modified  in  practice,  according  to  the  anatomic  struc- 
ture and  enxironments  of  the  diffeieut  joints  and  the  nature  of  the 
indications  that  call  for  the  operation.  In  opening  a  joint  for  the 
purpo.se  of  effecting,  b\-  diiect  measures,  reduction  of  an  irreducible 
dislocation,  the  incision  is  j)lanned  with  .special  reference  to  secure 
free  access  to  tJie  l)end  of  the  di.slocated  bone,  and  with  as  little  in- 
jury as  possible  to  ves.sels,  nerves,  muscles,  and  tendons.  The 
modern  operations  for  tuberculosis  of  joints  requiring  arthrectoniy 
or  re.sectif)n  are  characterized  by  tiiorougii  removal  of  the  di.sea.sed 
tissues  through  incisions  that  afford  free  access  to  tin'  joint,  and 
that  do  not  inflict  unnece.ssar\-  damage-  to  the  inipoitaiit  soft  struc- 
tures that  surround  the  joint. 

The  ultimate  success  of  resection  depends  largely  upon  the 
thoroughness  with  which  the  operation  is  performed,  the  care  exer- 
cised in  the  preservation  of  health)-  tissue,  and  the  prevention  of 
injury  to  impf)rtant  .structures  involved  at  the  site  o(  operation. 
The  modern  incisions  that  have  been  devised  for  resection  of  the 
different  joints  have  these  objects  in  view,  and  the  recent  imi)rove- 
ments   in   the   results   f)f  joint  surgery  are   largely  dn.-   t..   ;i    nimc 


I034  RESECTION    OF    JOINTS. 

nearly  perfect  technic  in  performing  the  operation.  The  success 
that  has  attended  the  open  method  in  the  reduction  of  irreducible 
dislocations  without  resection  of  the  head  of  the  dislocated  bone  has 
added  a  new  impulse  to  this  department  of  surgery.  Attempts  to 
reduce  old  dislocations  of  the  shoulder-joint  have,  in  the  hands  of 
the  most  careful  and  competent  surgeons,  frequently  terminated  in 
disaster,  so  that  the  surgeon  of  to-day  has  learned  caution,  and  is 
more  inclined  to  remove  the  obstacles  to  reduction  by  a  safe  and 
clean  dissection  than  by  brute  force.  The  same  can  be  said  of 
ancient  dislocations  of  the  hip-joint.  Every  surgeon  of  large  expe- 
rience has  had  his  patience  sorely  tried  in  efforts  to  reduce  recent 
dislocations  of  the  thumb.  The  cases  are  by  no  means  rare  in 
which,  by  the  employment  of  undue  force  during  such  attempts  at 
reduction,  much  damage  has  been  done  to  the  resisting  soft  struc- 
tures, which  could  have  been  avoided  by  effecting  reduction  by  the 
open  method,  under  aseptic  precautions. 

Resection  of  Finger=joints. — The  joint  is  exposed  by  two  lateral 
incisions  midway  between  the  extensor  tendon  and  the  digital  ves- 
sels and  nerves.  By  lateral  flexion  of  the  finger  the  articular  ends 
are  made  accessible,  and  after  they  are  cleared  of  soft  tissues,  are 
excised  with  fine  cutting  forceps  or  a  metacarpal  saw.  Unless  there 
is  sufficient  reason  to  doubt  the  aseptic  nature  of  the  wound,  the 
incisions  are  sutured  throughout,  and,  after  the  dressing  is  applied, 
the  finger  is  immobilized  in  a  slightly  flexed  position  upon  a  well- 
fitting  hollow  palmar  splint.  The  straight  position  must  be  avoided, 
as  in  the  event  of  ankylosis  taking  place  the  finger  would  be  useless. 
If  joint  motion  can  be  restored,  efforts  in  this  direction  must  be  made 
by  resorting  to  active  and  passive  motion  as  soon  as  the  wound  is 
healed. 

Resection  of  Wrist=Joint. — Bourgery  resects  the  wrist-joint 
through  two  lateral  incisions  ;  von  Langenbeck  through  a  straight 
dorsal  incision  over  the  middle  of  the  joint ;  and  Lister  through  two 
dorsal  incisions,  one  on  the  radial,  the  other  on  the  ulnar,  side.  If 
the  disease  for  which  the  resection  is  made  has  resulted  in  the  for- 
mation of  fistulse,  those  are  often  taken  as  a  guide  for  the  incisions. 

Perhaps  the  best  incision  so  far  devised  for  resection  of  the  wrist- 
joint  is  the  one  described  by  Kocher.  With  the  hand  slightly  flexed 
toward  the  radial  side,  an  incision  four  inches  in  length  is  made  from 
the  middle  of  the  interspace  between  the  fourth  and  fifth  metacarpal 
bones,  over  the  middle  of  the  joint  on  the  dorsal  side,  obliquely 
upward  and  toward  the  radial  side.  After  cutting  through  the  fascia 
and  the  hgamentum  carpi  dorsale,  the  joint  is  reached  between  the 
tendon  of  the  extensor  communis  and  extensor  of  the  little  finger, 
when  the  capsule  of  the  joint  is  opened  at  the  base  of  the  fourth 
metacarpal  bone.  After  detaching  the  extensor  ulnaris  tendon  from 
the  fifth  metacarpal  bone  and  lifting  from  its  groove  in  the  ulna  the 
extensor  tendon  of  the  little  finger,  the  soft  tissues  are  retracted  and 
the   joint  is  entered  between  the  pisiform  bone  and  the  lunatum, 


RESECTIOxN    OF    WRIST-JOIXT.  Iq^c- 

leaving  the  tendinous  insertion  of  the  flexor  carpi  uhiaris  with  the 
latter  bone  mtact.  The  tendon  of  the  flexor  ca'pir^d  ali"  '  not 
detached  from  the  second  metacarpal  bone,  but  the  tendon  of  "he 
supmator  longus  ,s  severed  from  the  styloid  process  of  the  radius 
The  hand  .s  now  dislocated  by  bending  it  forcibly  in  the  direction 
of  the  radms  and  the  flexor  side.  The  radiocarpa  joint  now  comes 
into  full  view,  and  the  diseased  carpal  bones  and  Articular  endTo? 


Fig-  578.  — Resection  of  wrist  joint  (after  Kocher). 


F'K-  579- — I-ister's  splint  for  rcsc(  (ion  >,{  wrisljoinl. 

the  radius,  ulna,  and  metacarpal  bones  can  be  removed  without  any 
difficulty.  After  the  resection  has  been  completed  and  hemorrhage 
arrested,  the  hand  is  brought  in  a  straight  position  and  the  exposed 
tendons  are  covered  by  suturing  the  deep  fa.scia  over  them  with  fine 
catgut.  The  hand  must  be  dre.s.sed  in  the  extended  position  with 
the  fingers  flexed,  and  immobilized  upon  a  wcll-j)ad(ie(l  anterior 
splint.  The  splint  should  reach  only  as  far  as  the  base  of  the 
fingers,  as  .stiffness  of  the   fingers  can  be  prevented  only  by  early 


1036 


RESECTION    OF    JOINTS. 


passive  and  active  motion.  The  hand  must  be  kept  in  the  extended 
position  for  several  weeks  and  sometimes  for  several  months,  as  the 
intrinsic  tendency  after  resection  of  the  wrist-joint  is  to  progressive 
flexion.  An  anterior  plastic  splint  extending  from  the  bend  of  the 
elbow  to  the  base  of  the  fingers,  and  including  the  ball  of  the  thumb, 
is  the  best  means  of  fixation  during  the  tedious  after-treatment. 


Fig.  580. — Von  Esmarch's  bracketed  suspension  splint  for  resection  of  wrist-joint. 


Resection  of  the  Elbow=joint. — Langenbeck's  straight  posterior 
incision  is  the  one  usually  selected  for  resection  of  the  elbow-joint 
with  or  without  temporary  resection  of  the  olecranon  process.  In 
all  cases  in  which  it  is  not  the  seat  of  extensive  disease  this  process 
should  be  temporarily  detached,  carefully  preserved,  replaced  after 
the  resection  has  been  completed,  and  united  with  the  shaft  of  the 
ulna. 

In  resection  of  this  joint  for  tuberculosis  I  have  frequently  made 
a  temporary  resection  of  the  olecranon,  and  when  the  articular 
surface  was  found  diseased,  it  was  removed  with  a  saw,  the  remain- 
ing fragment  being  saved  and  utilized,  the  results  being  the  best. 
If  only  the  cortex  to  which  the  triceps  tendon  is  attached  can  be 
saved,  this  should  be  done,  as  it  affords,  after  naihng,  the  best 
anchorage  for  the  important  triceps  muscle.  The  incision,  at  least 
five  inches  in  length,  is  made  equidistant  between  the  epicondyles 
of  the  humerus,  over  the  center  of  the  olecranon  process,  and  is 
continued  down  to  the  fascia  of  the  triceps  above  and  the  olecranon 
process  and  ulnar  ridge  below  the  joint.  In  detaching  the  soft 
tissues  from  the  posterior  aspect  of  the  joint,  special  care  is  neces- 
sary in  lifting  the  ulnar  nerve  out  of  its  groove  and  in  retracting 
the  tissues  on  that  side  with  a  blunt  hook  or  retractor.  After  the 
base  of  the  olecranon  process  has  been  reached,  the  arm  is  flexed, 


RESECTION    OF    THE    ELBOW-JOINT. 


lO 


0/ 


the  margins  of  the  wountl  carefully  retracted,  and.  with  a  Butcher's 
saw  or  chisel,  an  oblique  incision,  terminating  on  the  articular  side 
and  base  of  the  olecranon  process,  is  made  through  the  upper  end 
of  the  ulna.      The  ligamentous  connections  of  the  olecranon   are 


Fig.  58 1. — Dorsal  vertical  incision 
(l^ngenbecki  for  resection  of  the  elbow- 
joint,  exhibiting  olecranon  and  ulnar 
nerve  in  its  groove. 


Fig.    582. — Temporary   resection    of  ole- 
cranon with  chisel. 


Fig.  583.  —  Resection  completed. 


Fig.  584. — Olecranon  replaced  and  held  in 
place  Jjy  ivory  nail  and  calgiil  sul\ires. 


severed,  after  which  it  is  reflected  with  the  tendon  of  the  tncti)s 
iij)ward,  whcreii[)oii  the  joint  is  fully  expo.scd.  The  head  of  the 
radius  and  the  articular  ends  of  the  ulna  and  liutm-rus  can  be 
resected  with  .saw  or  chi.sel  without  any  difficulty  by  holding  the 
arm  in  a  hypcrflexed  pf)sitif)n.      After  the  resection  has  been  com- 


I038 


RESECTION    OF   JOINTS. 


pleted  and  the  hemorrhage  arrested,  the  arm  is  extended  and  the 
olecranon  fixed  in  position  with  an  aseptic  ivory  nail.  The  perios- 
teum should  be  sutured  separately  with  catgut.  The  arm  must  be 
immobilized  in  a  nearly  straight  position  for  three  or  four  weeks, 
until  the  olecranon  has  united  with  the  shaft  of  the  ulna  by  bony 
callus.  Later,  flexion  is  gradually  increased  day  to  day  until  the 
arm  is  at  a  right  angle,  when  active  and  passive  motion  is  employed 
systematically  and  persistently  to  secure  the  desired  range  of  joint 
motion.  Electricity  and  massage  will  do  much  in  aiding  these 
efforts  in  the  restoration  of  joint  function. 


Fig-  585- 


-Fenestrated  plaster-of- Paris  suspension  splint  after  resection  of  the  elbow- 
joint  (von  Esmarch). 


Fig.  586. — Bracketed  plaster-of-Paris  suspension  splint  (after  von  Esmarch). 

Resection  of  the  Shoulder=joint. — The  progress  of  surgery  of 
the  joints  during  the  nineteenth  century  can  be  well  shown  by  giving 
a  condensed  account  of  what  has  been  done  in  the  past  in  the  way 
of  devising  different  anatomic  routes  for  excision  of  the  shoulder- 
joint. 

Boucher  removed  parts  of  the  shoulder-joint  for  gunshot  wounds 
in  1753,  and  Thomas  opened  the  joint  for  the  extraction  of  necrosed 
bone  in  1740.  The  first  authenticated  case  of  resection  of  the 
shoulder-joint  was  performed  by  Ch.  White  and  not  by  Bent,  as 
stated  by  Treves  in  his  work  on  "Operative  Surgery,"  volume  i, 
page  647.  White  ("  Cases  of  Surgery,"  vol.  i)  performed  the  oper- 
ation  in    1768;    Bent,    of    Newcastle,   in    1771,   three   years   later. 


RESECTION    OF    THE    SHOULDER -JOINT.  IO39 

White's  patient  was  a  boy  of  fourteen,  who  was  the  subject  of  acute 
suppurative  inflammation  of  the  slioulder-joint,  terminatino-  in  the 
formation  of  an  extensive  abscess,  whicli  had  discliari,red  irscH"  ex- 
ternally. The  description  of  the  operation,  given  b>-  Mr.  White 
himself,  is  interesting  : 

"  I  began  my  incision  at  that  orifice  which  was  situated  just 
below  the  processus  acromion,  and  carried  it  down  to  the  middle  of 
the  humerus,  by  which  all  the  subjacent  bone  was  brought  into 
view,  then  took  hold  of  the  patient's  elbow  and  easily  forced  the 
upper  head  of  the  humerus  out  of  its  socket,  and  brought  it  so 
entirely  out  of  the  wound  that  I  readily  grasped  the  whole  head  in 
m}-  left  hand,  and  held  it  there  till  I  had  sawn  it  off  with  a  common 
amputation  saw,  having  first  applied  a  pasteboard  card  betwixt  the 
bone  and  the  skin.  I  had  taken  the  precaution  of  placing  an  assist- 
ant, on  whom  I  could  depend,  with  a  compress  just  above  the  clav- 
icle, to  stop  the  circulation  of  the  artery,  if  I  should  have  the  mis- 
fortune to  cut  or  lacerate  it  ;  but  no  accident  of  any  kind  iiappcned, 
and  the  patient  did  not  lose  more  than  two  ounces  of  blood  ;  only 
a  small  artery,  which  partly  surrounds  the  joint,  being  woundctl, 
which  was  easily  secured." 

The  patient  made  a  good  recovery,  and  four  months  later  left 
the  infirmary  completely  cured,  the  functional  result  being  excellent. 
Sequestration  of  the  sawed  surface  of  the  humerus  delayed  the  heal- 
ing of  the  wound.  Mr.  White's  example  was  followed  by  Bent  in 
1 77 1  and  by  Mr.  Orred,  of  Chester,  in  1778.  It  appears,  from  the 
accounts  we  have  of  the.se  operations,  that  the  disease  for  which 
they  were  performed  was  really  caries  of  the  shoulder-joint,  and  that 
the  patients  retained  limbs  which,  if  not  perfect,  were  at  least  ex- 
tremely useful.  Notwithstanding  this  encouragement  to  extend  the 
practice,  it  .seems  to  have  been  afterward  treated  in  England  witli 
entire  neglect. 

In  France  Moreau  the  elder  performeti  the  oi)erati()n  success- 
fully in  1786,  and  the  army  surgeons,  particularly  lianus,  Percy,  and 
Larrey,  frequently  re.sorted  to  it  in  recent  gunshot  wounds,  instead 
of  removing  the  limb.  In  Scotland  the  ojjeration  was  revived  i^y 
Mr.  Syme  in  1820,  and  was  later  performed  by  Babington,  Liston, 
Baddely,  l^'ergusson,  Lawrence,  Hunt.  Coote,  Hutchinson.  I'jich- 
sen,  Jiirkett,  .Stubbs,  lilackman,  and  others.  Jn  ("icrmany  the  first 
resection  of  the  shoulder-joint  was  made  by  Lentin  in  1771.  and  lie 
was  followed  by  Wutzer,  iM'icke.  Jager,  Blasius,  Te.xtor,  Diet/.,  llcy- 
felder,  Langenbeck,  Ivsmarch,  Wilms,  and  J^artels. 

The  variety  of  incisions  that  have  been  devised  for  e^•po^ing  the 
.shoulder-joint  with  a  view  to  re.sccting  the  inad  of  the  iuimc  rus  is 
.something  remarkable.  White's  original  incision  was  a  stiaight  one, 
extending  from  the  acromion  process  downward  through  the  center 
of  the  deltoid  muscle.  The  same  inci.sion  was  praeti.sed  by  Virgar- 
ru.s.  The  incisitjns  of  Larrey,  Kern,  Chassaigiiac,  and  Jiiger  are 
only  slight  modifications  of  White's  incision.      Jiaudens  commenced 


I040  RESECTION    OF    JOINTS. 

his  incision  just  below  the  coracoid  process  of  the  scapula,  and 
carried  the  knife  along  the  groove  between  the  pectoralis  major  and 
deltoid  muscles  to  the  groove  for  the  biceps  muscle.  If  this  incision 
did  not  afford  the  necessary  room  for  the  removal  of  the  diseased 
head  of  the  humerus,  he  enlarged  the  wound  by  making  two  small 
transverse  cuts  (but  only  through  the  muscles)  in  a  forward  direc- 
tion at  each  end  of  the  vertical  incision.  Langenbeck's  incision 
extends  from  the  anterior  border  of  the  acromion  process  near  the 
clavicular  junction,  in  a  vertical  direction  downward  through  the 
deltoid  muscle,  and  is  the  incision  that  has  usually  been  selected  for 
resection  of  the  shoulder-joint.  Baudens'  incision  was  somewhat 
modified  by  Malgaigne  and  Robert.  Frank  and  Reid  joined  the 
upper  end  of  the  anterior  vertical  incision  by  a  short  transverse  cut 
extending  beneath  the  acromion  process.  Bouzairies  joined  two 
oblique  incisions  in  the  shape  of  the  letter  V,  making  a  flap  including 
the  deltoid  muscle,  with  its  base  directed  upward.  Bent  made  a  long 
incision  from  the  joint  downward  in  the  furrow  between  the  pector- 
alis major  and  deltoid  muscles,  and  as  this  did  not  afford  enough 
room,  he  made  two  short  transverse  cuts,  one  meeting  the  upper  end 
of  the  long  cut  dividing  the  clavicular  attachment  of  the  deltoid 
muscle,  the  other  the  humeral  insertion  of  the  pectoralis  major, 
making  thus  a  quadrangular  flap  with  its  base  directed  toward  the 
body.  Bell,  Morel,  and  Guepratte  made  a  semilunar  incision  with 
its  base  directed  upward.  Wattmann  carried  the  knife  from  the  pos- 
terior margin  of  the  acromion  process  along  the  border  of  the  del- 
toid to  its  insertion,  and  joined  it  by  another  incision  extending  from 
the  tip  of  the  coracoid  process  to  the  same  point,  making  in  this 
way  a  triangular  flap  that  included  the  deltoid  muscle.  Sabatier's 
flap  incisions  are  the  same,  except  that  the  space  included  by  the 
incision  is  smaller.  The  elder  Moreau  made  a  quadrangular  flap 
with  its  base  directed  downward,  while  a  similar  flap,  with  its  base 
in  an  opposite  direction,  was  advised  by  Manne,  Percy,  the  younger 
Moreau,  Textor,  and  Jager.  Syme  made  a  perpendicular  incision 
from  the  acromion  through  the  middle  of  the  deltoid,  nearly  to  its 
point  of  insertion,  and  then  another  one  upward  and  backward,  from 
the  lower  extremity  of  the  former,  so  as  to  divide  the  external  part 
of  the  muscle. 

"The  flap  thus  formed  being  dissected  off,  the  joint  will  be 
brought  into  view,  and  the  capsular  ligament,  if  still  remaining, 
having  been  divided,  the  finger  of  the  surgeon  may  be  passed 
around  the  head  of  the  bone,  so  as  to  feel  the  attachments  of  the 
spinati  and  scapular  muscles,  which  can  then  be  readily  divided  by 
introducing  the  scapel  first  on  the  one  side  and  then  on  the  other. 
After  this  the  elbow  being  pulled  across  the  forepart  of  the  chest, 
the  head  of  the  humerus  will  be  protruded,  and  may  then  be  easily 
sawed  off,  while  grasped  in  the  operator's  left  hand." 

Albanese  makes  a  posterior  incision  in  the  shape  of  an  inverted  L, 
commencing  at  the  spine  of  the  scapula,  at  the  junction  of  this  with 


RESECTION    OF    THE    SHOULDER-JOINT.  1041 

the  acromion  process,  extending  from  above  downward  and  forward 
to  the  head  of  the  humerus,  from  where  it  is  directed  forward  ter 
mmatmg  at  the  tuberculum  majus.  The  muscles  are  separated 
with  the  periosteum,  and  through  the  wound  the  head  of  the  hu 
merus  is  removed.  It  is  claimed  that  this  incision  has  the  advantage 
over  other  posterior  incisions  that  it  does  not  endanger  the  circum- 
flex nerve.  OUier's  incision  extends  from  the  outer  border  of  the 
coracoid  process  of  the  scapula  in  the  direction  of  the  fibers  of  the 
deltoid  muscle,  obliquely  outward  and  downward,  a  distance  of  four 
or  five  inches,  to  the  shaft  of  the  humerus,  and  is  called  the  ante- 
rior oblique  incision.  Kocher's  posterior  curved  incision  is  com- 
menced over  the  acromioclavicular  joint,  extends  over  the  shoulder- 
joint  to  the  middle  of  the  crista  scapuLx,  and  is  continued  in  a 
curved  direction  downward  to  the  posterior  fold  of  the  axillaty 
space.  In  Kocher's  operation  the  acromion  process  is  temporarily 
detached  to  furnish  better  access  to  the  joint.  Bardenheuer's  in- 
cision passes  directly  over  the  acromion  process,  which  is  divided 
in  the  same  line  and  temporarily  detached. 

The  incision   devised  by  me   has  these  great  advantages  over 
Bardenheuer's,  that  the  scar  resulting  from  the  operation  is  well 
protected  by  the  prominence  formed  by  the  shoulder-joint,  and  at 
the  same  time  secures  free  access  to  every  part  of  the  shoulder- 
joint  and  its  immediate  vicinity.      The  external  incision  is  made  so 
as  to  form  an  oval  cutaneous  flap,  which  is  turned  upward,  expos- 
ing the  upper  half  of  the  deltoid  muscle  (Fig.  587).      It  is  com- 
menced over  the  coracoid  process,  and  is  carried  downward  and 
outward   in   a   gentle  curve  as   far  as   the   middle  of  the  deltoid 
muscle,  when  it  is  continued  in  a  similar  curve  upward  and  back- 
ward as  far  as  the  posterior  border  of  the  axillary  space,  on  the 
same  level  where  it  was  commenced — that  is.  a  point  opposite  the 
coracoid.      The  semilunar  flap  is  next  dissected  up  ^s  far  as  the 
base  of  the  acromion  process  and  reflected.     The  acromion  process 
is   detached   with   a   saw  and   turned   downward,  with  the  deltoid 
muscle  attached  (Fig.  588).      The  capsule  of  the  joint  is  now  freely 
exposed.      If  the  operation   is  performed  for  an  irreducible  disloca- 
tion of  the  shoulder-joint,  the  head  of  the  humerus  can  now  be 
located,  the  cause   of   resistance  to   reduction   is   sought  for  and 
removed  or  corrected,  when  the  reduction  can  be  accomplished  by 
manipulation    or    by   direct   measures    and    manipulation.      If    the 
operation  has  for  its  object  the  removal"  of  diseased  tissue,  the  cap- 
sule is  opened  and  the  interior  of  the  joint  subjected  to  a  careful 
examination,  to  determine  the  extent  of  the  operation.      If  the  dis- 
ea.se  is  limited  to  the  .soft  .structures,  a  cmnplete  arthrectom\'  can  be 
performed  without  sacrificing  any  portion  of  the  bony  constituc-nts 
of  the  joint  by  dislocating  the  head  of  the  humerus  in  diffc  ic  iit 
directions  for  the  purpo.se  of  rendering  the  entire  capsule  accessible 
to  the  di.s.secting  forceps,  knife,  and  scis.sors.      If  the  head  n(  the 
humerus  is  sufficiently  di.sca.sed  to  indicate  a  tyi)ical  resection,  it 
66 


I042 


RESECTION    OF    JOINTS. 


should  be  removed  as  a  preliminary  step  to  the  subsequent  arthrec- 
tomy.      The  glenoid   cavity  is    readily  accessible,   and   should   be 


Fig.  ^8y. — Senn's  method  of  resection 
of  the  shoulder-joint.  External  incision, 
flap  reflected,  and  saw  applied  over  base 
of  acromion. 


Fig.  588. — Temporary  resection  of 
acromion,  which  is  reflected  with  the  del- 
toid muscle  downward.  Head  of  humerus 
resected. 


Fig.  589. — Temporarily  detached  acro- 
mion replaced  and  fastened  in  position 
with  strong  catgut  sutures. 


Fig.  590. — Operation  completed. 


dealt  with  in  accordance  with  the  existing  pathologic  conditions. 
After  the  removal  of  all  diseased  tissue  and  proper  preparation  of 
the  wound,  the  acromion  process  is  replaced  and  held  in  position 


RESECTION    OF    THE    SHOULDER-JOIXT. 


1043 


by  two  or  three  Strong  catgut  sutures.  Silver  wire  is  seldom  re- 
quired in  suturing  a  temporarily  detached  bony  prominence  in 
operations  upon  the  different  joints.  The  catgut  sutures  hold  the 
fragment  long  enough  in  place  for  bony  union  to  occur.  Drilling 
of  the  bone  ends  is  unnecessary,  as  the  sutures  gain  a  sufficiently 
strong  hold  by  including  the  periosteum  and  the  paraperiosteal 
structures.  In  operating  upon  the  shoulder-joint  for  disease, 
through  tubular  or  capillary  drainage  should  be  established  and 


F'g-  591- — Kc.iccliijii  of  the  shouldc;  i.iiw>.f,ii  Lanj^ciiljcLk'.^  ;uiiuiiui  uiLi-Mon.  Divi- 
sion of  the  humerus  with  the  saw.  1  he  liead  of  the  bone  is  fixed  by  means  of  l.angen- 
beck's  forceps  (Zuckerkandl). 

continued  for  two  or  three  days.  Tlie  divided  portion  of  the  drl- 
toid  muscle  is  sutured  .separately  with  catgut,  when  tiie  ciitam-ous 
flap  is  brought  down  in  position  and  sutured  in  the  usual  inannc-r. 
In  operations  for  irreducible  dislocation  drainage  is  not  re(|uirc-d 
and  primary  healing  of  the  deep  and  superficial  wounds  should  be 
aimed  at  by  careful  hemostasis  and  suturing.  After  ajiplying  a 
copious  hygroscopic  a.scptic  dressing,  the  arm  should  he  immobil- 
ized again.st  the  side  of  the  che.st  witli  a  few  turns  of  tin-  pla.stt-r-of- 
Paris  Ijandage.     The   operatic^n    as   dcscrilnrd.  undertaken   for  the 


I044  RESECTION    OF    JOINTS. 

reduction  of  an  irreducible  dislocation,  arthrectomy,  or  resection  for 
disease  of  the  joint,  does  not  involve  any  of  the  important  tendons, 
muscles,  vessels,  or  nerves,  and  for  this  reason  a  good  functional 
result  may  be  confidently  expected. 

The  usual  method  employed  for  resection  of  the  shoulder-joint 
is  by  von  Langenbeck's  anterior  incision.  The  incision  is  com- 
menced at  the  anterior  border  of  the  acromion,  near  its  articular 
junction  with  the  clavicle,  and  is  carried  from  four  to  six  inches 
directly  downward,  extending  through  the  deltoid  muscle  down  to 
the  fibrous  capsule  and  the  periosteum.  On  retraction  of  the  mar- 
gins of  the  wound  the  long  tendon  of  the  biceps  can  be  seen  in  its 
groove.  An  incision  along  the  outer  border  of  the  tendon  opens 
its  sheath,  which,  together  with  the  capsule  of  the  joint,  is  then  laid 
open  as  far  as  the  acromion  process.  The  tendon  is  lifted  out  of  its 
groove  with  a  blunt  hook  and  drawn  outward.  While  an  assistant 
rotates  the  humerus  outward,  the  capsule  of  the  joint  and  the  inser- 
tion of  the  tendon  of  the  subscapular  muscle  are  severed.  The  arm 
is  then  rotated  inward,  and  the  tendon  of  the  biceps  is  displaced 
inward. 

The  next  step  of  the  operation  consists  in  dividing  the  tendons 
of  the  supraspinatus,  infraspinatus,  and  teres  minor  muscles  close 
to  their  insertion  into  the  greater  tuberosity  of  the  humerus.  The 
head  of  the  humerus  is  then  dislocated  forward  into  the  wound  by 
pressure  from  behind,  and  is  secured  with  a  grasping  forceps,  after 
which,  the  balance  of  the  capsule  being  divided,  it  is  removed  with 
a  chain  or  metacarpal  saw.  If  the  resection  is  made  for  an  infected 
comminuted  fracture  involving  the  head  of  the  humerus,  all  the  loose 
fragments  are  extracted  with  sequestrum  or  hemostatic  forceps,  and 
the  end  of  the  bone  is  properly  trimmed  with  bone-cutting  forceps. 
After  hemorrhage  has  been  arrested,  the  sheath  of  the  tendon  of  the 
biceps  should  be  sutured  separately  with  catgut.  If  drainage  is  re- 
quired, a  tubular  drain  reaching  from  the  glenoid  cavity  to  the  lower 
angle  of  the  wound  should  be  used,  the  balance  of  the  wound  closed 
by  suturing,  a  large  dressing  applied,  and  the  arm  well  supported 
and  immobilized  by  bandaging  it  to  the  side  of  the  chest  with  the 
forearm  flexed  at  a  right  angle. 

Resection  of  the  Metatarsophalangeal  Joint  of  the  Big  Toe. — 
Resection  of  this  joint  for  disease,  injury,  and  hallux  valgus  is  a 
legitimate  operation  and  yields  excellent  functional  results.  The 
joint  is  approached  through  a  straight  incision  half-way  between 
the  extensor  tendon  and  the  most  prominent  part  of  the  head  of 
the  metatarsal  bone.  With  knife  and  periosteal  elevator  all  the 
soft  tissues  are  detached  from  the  head  of  the  metatarsal  bone,  and 
the  joint  freely  opened  by  a  transverse  incision,  when,  by  bending 
the  toe  toward  the  plantar  surface  and  outer  margin  of  the  foot, 
and  with  the  aid  of  the  periosteal  elevator,  the  head  of  the  meta- 
tarsal bone  is  made  accessible  for  the  metacarpal  saw.  In  opera- 
tions for  hallux  valgus  the  entire  head  of  the  bone  is  removed  by 


RESECTION    OF    THE    ANKLE-JOINT.  1045 

making  a  transverse  section  through  the  bone  above  it.  Tlie 
articular  surface  of  the  proximal  phalanx  is  left  intact,  as  by  doing 
so  joint  motion  is  preserved.  After  suturing  the  wound  and  apply"^ 
ing  the  usual  aseptic  dressing,  the  toe  is  immobilized  bj-  an  inside 
splint,  including  the  inner  border  of  the  foot,  or  by  a  light  plaster- 
of-Paris  splint.  In  resections  of  this  joint  for  tuberculo.sis,  the 
head  of  the  metatarsal  bone  is  excised  first,  after  which'  the 
articular  end  of  the  proximal  phalanx  is  removed  with  bonc-cuttin*-- 
forceps,  the  entire  capsule  of  the  joint  then  being  made  easily 
accessible  for  a  complete  arthrectonn-. 

Resection  of  the  Ankle=joint. — Tuberculosis,  suppurative  pan- 
arthritis, infected  compound  fractures,  and  aggravated  cases  of 
equinovarus  are  the  usual  indications  for  resection  of  the  ankle-joint. 
Typical  resection,  including  the  malleoli,  the  articular  surfaces  of 
the  fibula  and  tibia,  and  the  entire  astragalus,  is  seldom  performed 
at  the  present  time.  The  modern  methods  of  ankle-joint  resection 
have  in  view  the  removal  of  diseased  and  the  preservation  of  healthy 
tissue. 

The  ankle-joint  is  so  constructed  that  it  is  somewhat  difficult  of 
access  without  dividing  important  structures  or  removing  some  of 
its  bony  constituents,  the  preservation  of  which  would  materially 
improve  the  functional  result.  To  overcome  the  difficulties  in  the 
way  of  gaining  free  access  to  this  complicated  joint  Hueter  proposed 
to  divide  all  the  tendons,  vessels,  and  nerves  by  an  anterior  incision 
from  one  malleolus  to  the  other,  reuniting  the  tendons  and 
nerves  by  suturing  after  the  excision.  This  inci.sion,  as  well  as  a 
similar  posterior  incision  proposed  by  another  surgeon,  has  never 
been  employed  to  any  extent,  as  both  inflict  too  much  injury  to 
important  .structures  that  should  be  carefull}' preserved.  A  wedge- 
shaped  excision  of  the  tarsus  for  the  correction  of  bad  cases  of 
equinovarus  can  be  made  through  a  lateral  incision  on  the  fibular 
side  without  sacrificing  any  important  muscular  insertions  or  cutting 
any  of  the  principal  vessels  or  nerves. 

In  resections  for  any  other  indication  the  ankle-joint  can  be 
made  accessible  for  all  practical  purposes  iiy  making  two  lateral 
inci.sions,  one  over  the  internal  and  the  other  over  the  external 
malleolus.  Langenbeck  makes  the  fibular  incision  in  the  form  of  a 
hook  by  starting  it  at  the  posterior  border  of  the  bone,  four  inches 
above  the  tip  of  the  malleolus,  following  the  border  of  the  fibula, 
and  cutting  around  the  margin  of  the  malleolus  to  its  ba.sc  in  front. 
On  the  inner  side  he  makes  a  crescent-shaped  incision  corresponding 
with  the  lower  margin  of  the  malleolus.  This  he  joins  by  a  straight 
incision  over  the  middle  of  the  tibia,  giving  to  the  inci.sion  thcshaj)c 
of  an  anchor.  Thron-h  these  incisions  the  malleolus  can  be 
excised,  after  which  the  ankle-joint  is  freely  exposed  to  sight  and 
touch  for  the  remaining  steps  f>f  the  opt:ration.  In  all  resections 
of  the  ankle-joint  the  chi.sel  should  take  the  place  of  llx-  .saw.  as 
its  use  inflicts  less  viok-ncr  on  the  soft  tissues  ;   moreover,  the  bones, 


1046 


RESECTION    OF   JOINTS. 


from  the  effects  of  disease  and  nonuse,  have  usually  become  osteo- 
porotic to  an  extent  sufficient  to  permit  their  ready  cutting  with  this 
instrument. 

Reverdin  and  Kocher  resect  the  ankle-joint  through  a  large 
external  lateral  incision  (Fig.  592).  The  knife  is  carried  on  a  level 
with  the  ankle-joint,  from  the  outer  margin  of  the  extensor  muscles 
in  a  curve  over  the  external  malleolus  as  far  as  the  tendo  Achillis. 
After  dividing  the  fascia,  the  extensor  tendons  and  the  tendon  of  the 


Fig-  592. — Resection  of  the  ankle-joint  by  the  method  of  Reverdin-Kocher ;   exposure 
of  the  ankle-joint  from  its  outer  aspect  (Zuckerkandl). 


Fig-  593-— First  stage  of  rotation  of  the  foot  at  the  ankle-joint  about  the  inner  malleolus 

(Zuckerkandl). 

peroneus  tertius  are  retracted  toward  the  tibial  side.  The  capsule 
and  ligaments  are  detached  from  the  anterior  margin  of  the  tibia 
and  fibula  and  the  margin  of  the  malleolus.  The  sheath  of  the 
peroneal  muscles  is  laid  open  widely,  and  the  tendons  are  lifted  out 
of  their  groove  and  drawn  backward  with  a  blunt  hook  ;  if  this  does 
not  procure  enough  space,  they  are  divided  and,  after  the  excision, 
united  by  tendon  suture.  All  the  soft  structures  in  front  of  the  joint 
capsule  and  sheath  of  the  extensors  are  next  separated  as  far  as  the 
internal  malleolus,  when  the  ankle-joint  can  be  readily  dislocated  by 


RESECTION    OF    THE    ANKLE-JOINT. 


1047 


forcibly  bending  the  foot  toward  the  tibial  side.      If  the  ligaments 
are  now  carefully  detached  from  the  margins  of  the  internal  malle- 
olus, the  joint  is  freely  exposed  to  inspection  and  touch,  and  the 
resection   can   be   made   to 
the  extent  indicated  by  the 
revealed  conditions. 

For  several  years  I 
have  resorted  to  temporary 
resection  of  the  malleoli  as 
a  preliminary  step  to  re- 
section of  the  ankle-joint. 
The  malleoli  with  the  over- 
lying soft  tissues  are  tem- 
porarily resected  in  the 
form  of  a  flap  that  is  re- 
flected downward,  the  liga- 
ments attached  acting  like 
a  hinge.  The  incision  is 
made  in  the  form  of  a 
horseshoe,  the  center  of 
which  corresponds  with  the 
base  of  the  malleolus,  and 
the  bars  with  the  anterior  and  posterior  borders.  With  a  thin 
chisel  the  base  of  the  malleolus  is  cut  through  on  a  level  with  the 
articular  surface  of  the  bone,  when  the  flap  is  turned  down,  opening 


Fig-  594- — Completed  rotation  ;  the  lower 
extremities  of  the  tibia  and  the  fibula,  as  well  as 
the  trochlea  of  the  astragalus,  are  completely  ex- 
posed (Zuckerkandl). 


'''K-  595- — Kesettiori  of  ankle-joint  by  temporary  resection  of  malleoli.      Fixation  of 

joint  after  resection. 


that  side  of  the  joint  freely.      Through  such  a  trap-door  inci.sion  the 
astragalus  can  be  removed  without  any  difficulty  by  fragmenting  it 


1048 


RESECTION    OF    JOINTS. 


with  a  chisel.  If  a  complete  arthrectomy  is  necessary,  both  malleoli 
are  temporarily  resected.  If  the  cartilages  of  the  malleoli  are  affected, 
they  are  removed  with  the  sharp  spoon  or  chisel.  After  the  resec- 
tion or  arthrectomy  has  been  completed,  the  flaps  are  replaced  and 
the  malleoli  fixed  in  position  by  two  or  three  catgut  sutures,  includ- 
ing the  periosteum  and  fibrous  tissue.  The  peroneal  tendons  on  the 
fibular,  and  the  flexor  tendons  on  the  tibial,  side  are  carefully  pro- 
tected by  retracting  them  with  a  blunt  hook.  Bony  union  between 
the  temporarily  detached  malleoli  and  the  articular  extremity  of  the 


Fig.    596. — Plaster-of-Paris   suspension    splint    for    resection    of  the  ankle-joint    (after 

von  Esmarch). 


Fig.  597- — Volkmann's  dorsal  splint  for  excision  of  the  ankle. 


tibia  and  fibula  takes  place  rapidly  and  satisfactorily,  provided  the 
wound  remains  aseptic. 

The  preservation  of  the  malleoli  in  the  manner  indicated  con- 
.tributes  much  to  the  ultimate  functional  result.  During  the  after- 
treatment  the  limb  must  be  immobilized  with  the  foot  at  a  right 
angle,  and,  if  need  be,  fixation  is  combined  with  suspension. 

Resection  of  the  Knee-^Joint. — From  a  technical  standpoint,  of 
all  the  large  joints,  the  knee-joint  presents  the  fewest  difficulties  to 
the  operator  in  performing  either  arthrectomy  or  resection.  Many 
are  the  incisions  that  have  been  devised  to  render  the  knee-joint 
accessible  to  direct  operative  treatment.  Textor  made  an  anterior 
curved    incision    with    the    convexity    directed    downward;    Hahn 


RESECTION    OF    THE    KNEE-JOINT. 


1049 


reversed  the  direction  of  the  curve,  cutting  through  the  tendinous 
insertion  of  the  quadriceps  extensor  femoris  muscle  above  the  patella. 
Volkniann  made  a  transverse  incision  over  the  center  of  the  patella, 
dividing  the  patella  on  the  same  plane.  Hueter  advocated  a  straight 
internal  lateral  incision,  while  Langenbeck  made  a  curved  incision 
on  the  same  side,  with  the  concavity  directed  backward.  Riedinger 
aimed  to  expose  the  knee-joint  by  a  vertical  median  anterior  incision, 
with  resection  of  the  patella  into  two  equal  lateral  halves. 

I  have  combined  Hahn's  superficial  incision  with  Volkmann's 
method  of  sawing  the  patella  transversely  in  the  middle,  and  have 
come  to  the  conclusion,  founded  on  a  somewhat  extensive  experi- 
ence, that  this  method  gives  the  freest  access  to  all  parts  of  the  interior 
of  the  joint,  and,  at  the  same  time,  yields  the  best  functional  results. 
A  curved  incision  is  made  from  one  epicondyle  of  the  femur  to  the 
other,  reaching  as  far  as  the  upper  border  of  the  patella,  and  extend- 
ing on  the  sides  down  to  the  bone  and   up  to  the  extensor  of  the 


Fig.  598. — Resection  of  the  knee-joint.    Exposure  of  the  patella  by  Hahn's  incision. 
Saw  in  position  for  Volkmann's  transpatellar  incision. 


quadriceps.  The  oval  flap  is  next  dissected  as  far  as  the  patellar 
tendon  and  reflected  downward.  With  an  amputation  saw  the 
patella  is  then  divided  transversely  in  the  middle,  and  the  lower 
fragment,  together  with  the  cutaneous  flap,  turned  down  as  far  as 
the  in.scrtion  of  the  tendon  of  the  patella.  The  upper  fragment, 
with  the  extensor  quadriceps  muscle,  is  turned  in  an  upward  direc- 
tion as  far  as  the  upper  limits  of  the  synovial  recess.  If  the  cap- 
sule is  much  thickened,  a  vertical  incision  on  each  side  of  the  patellar 
fragment,  extended  as  far  as  the  point  of  reflection,  will  facilitate  the 
exposure  of  the  entire  recess.  The  ligaments  of  the  joint  on  each 
.side  are  freely  divided  when  the  leg  is  acutely  flexed,  bringing  the 
.synovial  .sac  and  all  its  reces.scs  within  the  reach  of  sight  and  touch. 
In  operations  for  tuberculo.sis  the  next  stej)  of  the  operation 
consi.sts  in  excising  the  diseased  .synovial  membrane  and  capsule 
with   di.ssecting  forceps,  knife,  and  scissors.     The  recesses  behind 


1050  RESECTION    OF   JOINTS. 

the  head  of  the  tibia  and  the  condyles  of  the  femur  require  special 
attention  in  performing  this  part  of  the  operation.  In  atypical  re- 
section the  osseous  foci  are  sought  for  and  removed  with  the  sharp 
spoon  or  gouge  and  hammer.  Before  suturing  the  wound,  such 
cavities  must  be  thoroughly  cleansed  by  mopping  with  iodoform 
gauze  sponges,  iodoformized,  and  packed  with  decalcified  bone 
chips. 

In  1889  I  made  numerous  experiments  concerning  the  utility 
of  decalcified  bone  chips  in  the  healing  of  aseptic  bone  cavities,  and 
the  results  obtained  were  entirely  satisfactory.  The  clinical  experi- 
ence for  a  period  of  ten  years  has  more  than  realized  all  expecta- 
tions. A  sine  qua  non  for  success  is  asepticity  of  the  cavity.  The 
most  favorable  cases  for  this  procedure  are  bone  tuberculosis  with- 
out mixed  infection,  circumscribed  osteomyelitis,  and  small  cavities 
after  sequestrotomy. 

The  same  procedure  in  the  form  of  discs  or  plates  has  also 
proved  very  successful  in  the  treatment,  primary  or  secondary,  of 
large  cranial  defects. 

The  directions  for  preparing  the  decalcified  bone  and  for  its  im- 
plantation are  as  follows  : 

General  Directions  for  Treatment  of  Bone  Defects  by  Iniplan= 
tation  of  Antiseptic  Decalcified  Bone. — /.  Decalcification  and  Dis- 
infection of  Bone. — A  fresh  tibia  of  an  ox  is  the  best  material  for 
decalcification.  The  bone  is  cut  in  sections  two  inches  in  length, 
and,  after  carefully  removing  the  medullary  tissue,  is  kept  in  dilute 
muriatic  acid,  the  fluid  being  changed  every  few  days  until  the 
process  of  decalcification  has  been  completed.  After  this  has  been 
accomplished  the  bone  can  readily  be  cut  into  pieces  about  one  milli- 
meter in  thickness,  making  the  sections  parallel  to  the  long  axis  of 
the  bone.  The  acid  is  then  removed  by  washing  and  by  keeping 
the  bone  immersed  in  a  weak  solution  of  caustic  potash.  The  bone 
is  then  rendered  antiseptic  by  keeping  it  until  needed  in  a  solution 
of  sublimate  in  alcohol  i  :  500,  in  a  wide-mouthed  bottle  that  is  kept ' 
hermetically  sealed  by  a  glass  stopper  to  prevent  evaporation  of  the 
solution.  When  the  bone  is  needed,  it  is  taken  from  the  bottle  and 
placed  in  a  5  per  cent,  solution  of  carbolic  acid  or  a  weak  solution 
of  sublimate.  In  making  the  plates  or  discs  for  filling  a  cranial 
defect  the  bone  is  cut  so  as  to  correspond  in  thickness  to  the  bone 
removed,  and  accurately  to  fit  into  the  opening.  A  number  of  small 
perforations  in  the  disc  or  plate  should  always  be  made,  as  through 
these  openings  the  space  underneath  the  bone  is  kept  drained  ;  at 
the  same  time  the  early  entrance  of  granulation  tissue  into  these 
openings  effects  fixation  of  the  bone  in  situ,  and  favors  the  early 
removal  of  the  implanted  substance  by  substitution  with  permanent 
living  tissue.  Before  implantation  both  sides  of  the  plate  should  be 
dusted  with  iodoform.  For  packing  bone  cavities  the  decalcified 
bone  should  be  cut  in  thin  slices  or  chips,  which  should  be  laid  upon 


ASEPSIS    AT    THE    SEAT    OF    IMPLANTATION.  IO51 

a  compress  of  aseptic  gauze,  so  as  to  remove  the  surface  moisture, 
when  they  are  dusted  with  iodoform  before  they  are  implanted  into 
the  cavity.  /Iseptic  decalcified  bone  drains,  in  the  absence  of  more 
suitable  material,  can  be  used  in  packing  bone  cavities. 

2.  Asepsis  at  the  Seat  of  Implantation. — The  most  essential  con- 
dition for  success  in  the  treatment  of  bone  defects  by  implantation 
of  decalcified  bone  is  a  perfectly  aseptic  condition  of  the  tissues  to 
be  brought  in  contact  with  the  implanted  bone.  This  condition  is 
easily  procured  in  operations  on  bones  for  lesions  other  than  those 
caused  by  infection  with  pus-microbes,  such  as  tumors,  parasites, 
and  tuberculous  and  syphilitic  affections  uncomplicated  by  suppura- 
tion. In  the  surgical  treatment  of  these  affections,  after  the- removal 
of  the  diseased  tissue  the  seat  of  operation  must  be  aseptic  if  the 
ordinaiy  precautions  for  the  prevention  of  infection  from  without 
have  been  observed.  In  such  cases  speedy  healing  of  the  external 
wound  and  the  early  partial  or  complete  reproduction  of  the  lost 
bone  are  assured. 

The  next  most  favorable  cases  for  bone  implantation  are  circum- 
scribed osteomyelitic  processes  in  the  epiphyseal  extremities  of  the 
long  bones,  as  we  observe  them  in  cases  of  primary  circumscribed 
epiphyseal  osteomyelitis,  or  in  the  form  of  a  recurring  attack  in  the 
same  place,  perhaps  years  after  a  diffuse  osteomyelitis  of  the  entire 
shaft.  Under  such  circumstances  the  inflammatory  focus  can  be 
located  externally  by  the  presence  of  a  circumscribed  area  of  ten- 
derness, the  tender  spot  constituting  the  guide  in  the  search  for  the 
abscess.  The  seat  of  inflammation  is  freeh'  exposed  with  a  chisel, 
and  the  walls  of  the  abscess  cavity  are  scraped  out  with  a  sharp 
spoon  until  healthy  tissue  is  reached  all  around.  The  precaution 
should  be  taken  to  wash  out  the  cavity  with  an  antiseptic  solution 
before  attacking  the  abscess  wall,  so  as  to  prevent  the  contamina- 
tion of  the  healthy  tissue  with  the  products  of  the  infection  by  the 
mechanical  diffusion  of  the  pus-microbes.  For  the  final  disinfection 
of  such  a  cavity  a  strong  solution  of  sublimate  is  used,  and,  after 
thoroughly  drying  its  walls,  it  is  dusted  with  iodoform.  lodoform- 
ization  of  the  cavity  and  the  implantation  of  antiseptic  bone  chips 
are  measures  well  calculated  to  resist  the  pathogenic  action  of  pus- 
microbes  that  might  still  remain,  and,  in  the  majority  of  cases,  will 
secure  an  aseptic  healing  of  the  wound. 

This  method  of  treating  bone  cavities  is  also  applicable  after 
operations  for  necrosis  resulting  from  a  previous  attack  of  acute 
suppurative  o.stcomyelitis.  With  a  view  to  obtaining  an  aseptic 
condition  of  the  cavity  it  is  ncces.sary  that  the  line  of  demarcation 
between  dead  and  living  tissue  should  have  formed,  the  involucrum 
must  be  well  developed,  and  the  soft  parts  in  a  healthy  condition. 
The  operation  that  precedes  the  iniplanfcition  must  accomplish  more 
than  the  sim[)le  extraction  of  the  necro.setl  bone  :  it  implies  the  re- 
moval of  all  infected  ti.ssue  lining  the  interior  of  the  involucrum 
and  the  fi.stulous  tracts  in  the  soft  ti.ssues.      The  involucrum  must 


1052  RESECTION    OF    JOINTS. 

be  laid  open  with  the  chisel  sufficiently  to  expose  to  sight  and  direct 
treatment  its  entire  interior  for  the  purpose  of  removing  with  the 
sharp  spoon  all  the  infected  granulations ;  at  the  same  time  the  fistu- 
lous tracts  in  the  soft  tissues  must  be  made  accessible  to  the  same 
treatment.  After  the  thorough  mechanical  removal  of  all  infected 
tissues  the  wound  surfaces  must  be  irrigated  freely  with  a  hot  solu- 
tion of  sublimate,  and  for  final  disinfection  a  1 2  per  cent,  solution  of 
chlorid  of  zinc  may  be  applied  with  a  brush,  after  which  the  cavity 
is  flushed  again,  dried,  and  iodoformized.  In  operations  for  acute 
diffuse  osteomyeHtis  all  known  surgical  resources  are  inadequate  in 
rendering  the  field  of  operation  aseptic,  and  hence  implantation  with 
decalcified  bone  is  contraindicated. 

J.  Necessity  of  Performing  the  Operation  by  Bloodless  Method. — 
I  have  previously  made  the  statement  that  in  the  implantation  of  a 
disc  or  plate  of  bone  into  a  defect  in  the  skull  the  hemorrhage  from 
the  brain  and  its  coverings  should  be  carefully  arrested  before  the 
implantation  is  made,  as  otherwise  compression  of  the  brain  might 
arise  from  accumulation  of  blood  underneath  the  implanted  bone. 
The  disc  or  plate  may  be  relied  upon  in  arresting  hemorrhage  from 
the  vessels  in  the  bone  that  other  measures  have  failed  to  control. 
In  the  treatment  of  bone  cavities  in  regions  where  it  is  possible  to 
render  the  operation  bloodless  by  elastic  constriction  this  should 
always  be  employed,  as  it  prevents  unnecessary  loss  of  blood  dur- 
ing the  operation  and  enables  the  surgeon  to  resort  to  means  and 
measures  for  procuring  an  aseptic  con'dition,  which  otherwise  it 
would  be  impossible  to  apply  with  the  same  degree  of  thoroughness 
and  efficiency.  Unless  special  indications  present  themselves,  the 
elastic  constriction  is  continued  until  after  the  dressing  has  been 
applied. 

^.  Implantation. — In  the  treatment  of  a  bone  cavity  by  implanta- 
tion with  decalcified  bone,  the  chips  are  poured  into  the  cavity  and 
are  packed  quite  firmly  until  the  surface  of  the  cavity  is  reached. 
The  bone  chips  act  as  an  antiseptic  tampon,  arresting  the  free  oozing 
from  the  surface  of  the  bone,  which  always  takes  place  after  the 
removal  of  the  constrictor.  Some  blood  escapes  between  the  bone 
chips  and  coagulates  at  once,  thus  forming  a  desirable  and  useful 
cement  substance,  which  permeates  the  entire  packing  and  tempo- 
rarily glues,  as  it  were,  the  chips  together  and  the  entire  mass  to 
the  surrounding  tissues. 

5.  Treatment  of  External  Wound. — The  periosteum  should  be 
carefully  preserved  in  exposing  the  bone,  and,  after  the  implantation, 
is  sutured  over  the  surface  of  the  bone  chips  with  catgut  sutures. 
If  the  bone  is  deeply  located,  it  may  become  necessary  to  apply 
another  row  of  buried  sutures  in  bringing  into  accurate  apposition 
other  soft  parts.  The  skin  is  finally  sutured  with  silk.  It  is  of 
great  importance  to  secure  accurate  apposition  of  the  divided  soft 
parts  in  order  to  preserve  for  the  subjacent  bone  all  its  natural 
coverings. 


SECONDARY    IMPLANTATION.  IO53 

6.  Drainage. — In  some  instances  it  would  be  undoubtedly  super- 
fluous to  secure  any  form  of  drainage,  as  when  the  cavity  is  per- 
fectly aseptic  and  hemorrhage  is  not  in  excess  of  requirements, 
healing  of  the  entire  wound  would  be  accomplished  under  one 
dressing.  Experience,  however,  has  taught  me  that  tension  arising 
from  extravasation  of  blood  often  exerts  an  injurious  influence  upon 
the  process  of  healing  and  should  be  carefully  avoided.  As  it  is 
desirable  to  heal  as  much  of  the  wound  as  possible  without  interfer- 
ing with  drainage,  I  have  invariably  introduced  an  absorbable  capil- 
lar)' drain  in  the  lower  angle  of  the  wound.  A  string  of  catgut 
twisted  into  a  small  cord  answers  an  admirable  purpose. 

7.  Dressing  of  Mound. — The  wound  is  covered  with  a  strip  of 
aseptic  silk  over  which  a  itw  layers  of  iodoform  gauze  are  applied. 
Over  this  a  cushion  of  sterile  gauze  is  placed  with  a  thick  layer 
of  salicylated  cotton  along  its  margins,  for  the  purpose  of  guarding 
more  securely  against  the  entrance  of  unfiltered  air ;  the  whole  of  it 
is  retained  b}'  a  circular  bandage  of  gauze  evenly  and  smoothly  ap- 
plied. For  the  purpose  of  securing  absolute  rest  for  the  limb  it  is 
placed  upon  a  posterior  splint  and  kept  in  a  slightly  elevated  posi- 
tion. If  no  indications  arise,  the  first  dressing  is  not  removed  for 
two  weeks,  when  the  entire  wound  will  usually  be  found  healed, 
except  a  few  granulations  at  the  place  where  the  catgut  drain  was 
inserted.  A  smaller  antiseptic  compress  is  applied,  and  the  limb 
dressed  in  a  similar  manner.  It  is  advisable  to  enforce  rest  nut 
only  until  the  external  wound  has  healed,  but  until  the  whole  pro- 
cess of  repair  has  been  completed,  which  embraces  a  period  varying 
from  four  weeks  to  three  months,  according  to  the  size  of  the  cavity 
and  the  age  of  the  patient. 

8.  Secondary  Implantation. — If  an  operation  is  followed  by  sup- 
puration the  result  of  imperfect  antisepsis,  tubular  drainage  must  be 
established  and  the  same  treatment  pursued  as  in  suppurating 
wounds.  If  suppuration  takes  place  soon  after  the  operation  and  is 
profuse,  it  is  probable  that  all  the  bone  chips  will  be  lost.  It  it  de- 
velops after  granulation  tissue  has  had  time  to  form  and  the  purulent 
discharge  is  moderate  in  quantity,  the  prospects  are  that  the  bone 
will  remain  and  serve  its  purpose  as  a  nidus  for  the  granulation 
tissue.  In  such  ca.ses  an  antiseptic  irrigation  should  be  made  every 
three  or  four  days  until  suppuration  has  ceased.  If  the  bone  chips 
are  lost  by  suppuration  or  have  to  be  removed  for  the  purpose  of  a 
more  thorough  disinfection  of  the  cavity,  no  attempt  should  be 
made  at  rcimi^lantation  until  suppuration  has  been  arrested,  or,  ni 
other  words,  until  the  cavity  has  become  lined  with  granulations 
and  is  in  a  comparatively  aseptic  condition,  when  the  time  for 
.secondary  implantation  has  arrived.  After  the  cavity  has  been  irri- 
gated with  a  strong  anti.septic  solution,  it  is  dusted  with  iodoform 
and  the  granulations  are  scarified  in  a  number  of  places  for  the  i)ur- 
pose  of  obtaining  a  sufficient  amount  of  blood  to  fill  the  spaces  be- 
tween the  bone  chips,  which  are  implanted  in  the  same  manner  as 


I054 


RESECTION    OF   JOINTS. 


in  the  treatment  of  a  recent  cavity.  Complete  closure  of  the  ex- 
ternal wound  under  these  circumstances  is  seldom  obtainable,  and 
the  surface  of  the  exposed  portion  of  the  cavity  should  be  provided 
with  a  thin  layer  of  Schede's  moist  blood-clot.  The  antiseptic 
properties  of  the  material  used  in  packing  the  cavity  exert  a  potent 
influence  in  maintaining  asepticity  after  secondary  implantation. 

If  it  is  the  object  of  the  operation  to  make  a  typical  resection, 
the  articular  surfaces  are  removed  on  both  sides  and  the  sections 
through  the  bone  made  in  a  slightly  oblique  direction,  so  that  when 
the  resected  ends  are  brought  in  contact,  the  leg  will  be  slightly 
flexed.  Fenwick,  of  Canada,  makes  the  sections  through  the  bone 
in  such  a  way  that  when  the  surfaces  are  brought  in  contact  antero- 
posterior displacement  can  not  take  place — that  is,  the  resected  sur- 
face on  the  femur  side  is  made  convex,  and  on  the  tibial  side  con- 
cave. A  bow  with  a  scroll  saw  is  the  best  instrument  for  making 
such  curved  incisions  in  bone.    Kocher  and  Helferich  have  described 

the  same  method  of 
dealing  with  the  bone- 
ends,  but  the  credit  of 
utilizing  the  sawn  sur- 
faces as  means  of  fixa- 
tion belongs  to  Fenwick. 
Fixation  by  the  use  of 
silver-plated  stout  nails 
driven  through  the  skin 
and  the  resected  ends, 
as  suggested  by  Hahn, 
is  superfluous,  as  ade- 
quate fixation  can  be 
secured  by  a  well-fitting 
external  support  and  the 
Fig.  599. — Typical  resection  of  the  knee-joint.  ^^^     of      buried      catgut 

sutures. 
The  most  painstaking  hemostasis  must  precede  suturing  of  the 
wound.  Parenchymatous  oozing  from  the  cancellated  bone,  often 
proving  quite  troublesome,  usually  yields  promptly  to  the  use  of 
hot  water  and  surface  compression.  The  patella  must  invariably  be 
preserved  if  it  is  not  the  seat  of  extensive  disease.  In  operating  for 
joint  tuberculosis,  in  case  the  disease  has  disintegrated  the  cartilage, 
a  thin  slice  is  removed  from  its  lower  surface  with  the  saw.  Sutur- 
ing of  the  patella  with  catgut  suffices  to  hold  the  fragments  in  con- 
tact until  bony  union  has  taken,  place.  I  have  never  failed  in  ob- 
taining bony  union  by  suturing  with  catgut  after  resection  of  the 
knee-joint. 

In  suturing  the  patella,  a  large  curved  needle  and  the  strongest 
catgut  are  used.  The  first  suture  is  a  broad  mattress  suture,  em- 
bracing at  two  points  the  periosteum  and  tendinous  portion  of  the 
quadriceps    above,  and  the   periosteum  and  fibers  of  the   patellar 


SECONDARY    IMPLANTATION. 


1055 


tendon  below.  A  suture  on  each  side  of  the  patella  with  catgut  of 
the  same  size  and  a  few  periosteal  sutures  of  fine  catgut  inside  of  the 
mattress  suture  complete  the  direct  fixation  of  the  patellar  fragments. 
On  the  sides  of  the  joint  the  deep  tissues  are  united  with  buried 
catgut  sutures  before  the  flap  is  replaced  and  sutured  with  silkworm- 
gut  and  horsehair.      Drainage  should  be  limited  to  the  insertion  of 


Fig.  600.  —  Suturine  of  the  patella  and  capsule  of  the  joint  with  catgut. 


Fig.  601.— Operation  completed.      Capillary  drainage  through  a  separate  buttonhole  on 
tibial  side,  near  the  line  of  suturing. 

a  bundle  of  catgut  into  each  angle  of  the  wound  or  into  a  separate 
buttonhole. 

During  the  suturing,  dressing,  and  immobilization  of  the  hmb  a 
reliable  a.?sistant  mu.st  hold  tiie  leg  and  thigh  in  proper  position. 
The  dressinfT  for  the  wound  must  be  copious,  and  include  at  least 
one-half  of  "the  leg  and  thigh.  A  well-fitting  hollow  postcnor 
splint,  reaching  from  the  tuberosity  of  the  ischium  to  the  heel,  and 
supplied  with  a  foot-board  at  a  right  angle,  should  be  rchcd  upon 
for  at  lea.st  a  few  days  in  immobilizing  the  limb.      Later,  a  po.sterior 


1056 


RESECTION    OF   JOINTS. 


plaster  splint  will  answer  the  purpose  until  the  wound  is  healed, 
when  a  circular  plaster-of- Paris  splint  should  be  applied  and  allowed 
to  remain  until  the  bony  union  is  sufficiently  firm  to  abandon  any 
kind  of  external  support. 

Restoration  of  motion  after  arthrectomy  is  not  only  possible,  but 
probable,  but  no  attempts  in  this  direction  must  be  made  until  the 
patella  has  united  by  bony  consolidation,  which  requires,  under  the 
most  favorable  conditions,  from  five  to  six  weeks.  The  first  efforts 
in  restoring  motion  often  demand  the  use  of  an  anesthetic,  and  what 
little  is  gained  must  be  maintained  and  increased  by  passive  and 
active  motion,  systematic  massage,  and  the  use  of  electricity. 

In  a  typical  resection  in  children  the  epiphyseal  cartilages  must 
not  be  included  in  the  excision,  for,  even  if  the  operation  prove  suc- 
cessful, shortening  of  the  limb  will  take  place  to  an  extent  incom- 
patible with  walking  without  some  kind  of  mechanical  aid. 


Fig.  602. — Plaster-of- Paris  suspension  splint  for  resection  of  the  knee-joint,  after 
Watson  (von  Esmarch). 

Resection  of  the  Hip=joint. — One  of  the  striking  indications  of 
the  progress  made  in  the  treatment  of  tuberculosis  of  the  hip-joint 
is  the  progressive  diminution  of  the  number  of  cases  in  which  resort 
to  resection  is  deemed  necessary.  Only  a  decade  ago  resection  of 
the  hip-joint  for  tubercular  coxitis  was  a  common  operation,  both 
in  private  and  hospital  practice,  while  at  the  present  time  it  is  seldom 
witnessed,  even  in  the  large  clinics.  An  immense  experience  has 
demonstrated  that,  on  the  whole,  better  results  follow  the  conserva- 
tive than  the  operative  treatment.  Rest  in  bed  or  fixation  of  the 
joint  by  an  orthopedic  appliance,  intra-articular  injections  of  iodoform 
glycerin  emulsion,  the  internal  administration  of  guaiacol,  and  a 
nutritious  diet  conscientiously  and  persistently  carried  out  have  been 
found  so  successful  in  the  management  of  tuberculosis  of  the  hip- 
joint  that  typical  resection  is  seldom  deemed  necessary.  Reduction 
of  the  irreducible  dislocations  of  the  hip-joint  under  pedantic  aseptic 
precautions  has  become  an  established  surgical  procedure  and  has 
yielded  the  most  gratifying  results. 

Resection  is  also  indicated  in  acute  suppurative  synovitis,  as  a 


RESECTION    OF    THE    HIP-JOINT. 


105; 


Fig.  603.  —  Resec- 
tion of  the  hipjoint  by 
the  curved  incision  of 
A.  White  (Tillmanns). 


primary  affection  or  secondary  to  osteom^-elitis  of  the  upper  end  of 
the  shaft  of  the  femur;  if  suppuration  does  not  vield  to  free  drain- 
age and  antiseptic  irrigation,  or  if  the  head  of  the  femur  has  become 
separated  in  consequence  of  the  inflammatory 
disease.  Invasion  of  the  hip-joint  may  also 
become  necessary  in  ununited  fracture  of  the 
neck  of  the  femur  in  youthful  patients,  and 
for  the  removal  of  fragments  in  comminuted 
infected  fractures  of  the  joint.  Ordinarily 
the  great  trochanter,  the  point  of  anchorage 
of  most  important  muscles,  is  not  damaged  to 
any  extent  by  the  injury  or  disease  that  makes 
the  operation  necessary,  and  on  that  account 
should  not  be  included  in  the  resection.  In 
all  cases  in  which  the  hip-joint  is  approached 
by  a  lateral  incision  the  trochanter  major 
should  be  resected  temporarily  if  it  is  not 
involved  sufficiently  to  demand  removal.  It 
is  in  resections  of  the  hip-joint  that  the  im- 
portant rule  to  limit  the  excision  to  useless  or 

diseased  parts  is  most  frequently  ignored.  During  the  last  eight 
years  I  have  never  found  it  necessary  to  remove  the  great  trochan- 
ter in  my  operative  work  on  the  hip-joint,  and  I  have  become  fully 

convinced  that  its  preservation 
has  contributed  much  to  the 
functional  result. 

A  number  of  incisions  have 
been    recommended  for  resec- 
tion of  the  hip-joint.    Anthony 
White     favored     a     posterior 
curved  incision  ;  von   Langen- 
bcck   made  a  straight  incision 
over  the  center  of  the  great  tro- 
chanter, and    Luccke,   Hueter, 
and   Schede  recommended  the 
anterior  route.      For  resection 
of  .the   liip-joint   with  tempor- 
ary resection  of  the  trochanter 
major     White's     incision     de- 
serves   the    first  choice.      The 
incision   begins  on  a  line  with 
and   half-way  between   the  an- 
terior superior  spinous  process 
of    the    ilium    and    trochanter 
major,    passes    over   the   most 
prominent  point  of  the  upper  horrler  of  the  trochanter,  and  folhws 
the  i)osterior  bc^rder  for  a  distance  of  three  inches.      The  oval  flap, 
including  all   the  ti.ssues  down   to  the   muscles   and  perio.steum,  is 
67 


Fig.  604. — Resection  of  the  hip  joint. 
Vertical  incision,  after  von  I,angenl)cck 
(  "  American  Text  book  of  Surgery  "). 


1058 


RESECTION    OF    JOINTS. 


reflected  forward  sufficiently  to  expose  well  the  base  of  the  tro- 
chanter. With  a  broad,  thin,  sharp  chisel  the  trochanter  is  reversed 
by  an  oblique  cut,  including  a  thin  triangular  piece  of  the  shaft  of 
the  femur.  The  trochanter,  with  the  muscles  attached,  is  then  re- 
flected upward  in  the  form  of  a  deep  flap.  Retraction  of  the  wound 
margins  in  three  directions  and  incision  of  the  capsular  ligament 
now  expose  the  neck  of  the  femur,  which  is  cut  through  with  the 
chisel  at  a  safe  distance  from  the  disease,  and  the  head  is  extracted 
with  grasping  forceps,  or  enucleated  with  the  periosteal  elevator. 
The  removal  of  the  head  of  the  femur  and  whole  or  part  of  its  neck 
exposes  the  capsule  freely  for  the  subsequent  arthrectomy. 

After  the  excision  and  arthrectomy  have  been  completed,  the 
hemorrhage    carefully   arrested,   and    the    acetabulum    thoroughly 

cleaned  with  the  sharp  spoon,  the  tro- 
chanter is  replaced  and  fixed  in  position 
with  an  aseptic  bone  or  ivory  nail,  aided 
by  sutures  of  catgut  embracing  the  peri- 
osteum and  the  dense  fascia.  In  a  num- 
ber of  cases  I  have  relied  on  suturing 
with  catgut  exclusively  in  immobilizing 
the  trochanter,  and  had  the  satisfaction 
of  observing  that  the  trochanter  was 
perfectly  held  in  place  until  bony  union 
was  sufficiently  firm  to  dispense  with  di- 
rect means  of  fixation.  The  acetabulum 
is  drained  with  a  tubular  drain  and  iodo- 
form gauze,  which  are  brought  out 
through  a  separate  opening  behind  the 
resection  wound.  The  dressing  must  be 
large,  embracing  the  upper  half  of  the 
thigh  and  the  same  side  of  the  pelvis  as 
far  as  the  crest  of  the  ilium.  As  a  pri- 
mary immobilization  dressing  a  long  ex- 
ternal splint  with  foot-board  and  exten- 
sion by  weight  and  pulley  will  be  most 
comfortable  and  efficient.  As  soon  as  the  patient  is  able  to  leave 
his  bed,  a  plaster-of- Paris  dressing  is  relied  upon  in  securing  fixa- 
tion and  in  guarding  against  undue  shortening. 

Luecke's  anterior  incision  is  an  excellent  one  for  the  extraction 
of  loose  sequestra  and  resection  of  the  head  of  the  femur,  but  it  does 
not  furnish  the  required  space  for  a  complete  arthrectomy.  The  in- 
cision begins  immediately  below  and  a  fingerbreadth  to  the  inside 
of  the  anterior  superior  spinous  process  of  the  ilium,  and  is  extended 
vertically  downward  to  the  level  of  the  trochanter  minor.  The 
inner  margin  of  the  sartorius  and  rectus  femoris  is  laid  bare  and 
retracted  outward.  By  blunt  dissection  the  outer  margin  of  the 
iliopsoas  muscle  is  reached  and  is  retracted  inward.  The  capsule 
of  the  joint  is  made  accessible  by  slight  flexion,  abduction,  and  out- 


Fig.  605. — Resection  of  the 
hip-joint ;  Luecke's  anterior  in- 
cision :  A,  Gluteus  muscle ;  B, 
tensor  vaginse  femoris  muscle ; 
C,  sartorius  muscle. 


AMPUTATIONS    AND    DISARTICULATIONS.  IO59 

ward  rotation  of  the  thigh.  The  capsule  is  then  incised,  and  the 
neck  of  the  femur  severed  with  a  small  saw,  or,  what  is  decidedly- 
better,  with  chisel  and  hammer.  After  cutting  away  the  cartilagin- 
ous margin  of  the  acetabulum,  the  head  of  the  femur  is  extracted 
with  forceps,  or  lifted  out  of  the  acetabulum  with  the  periosteal 
elevator.  Luecke's  operation  has  the  decided  advantage  of  not 
requiring  the  severance  of  any  muscles  or  tendons,  besides  obviating 
the  necessit)'  of  sacrificing  or  temporarily  detaching  the  trochanter 
major  in  opening  up  a  comparatively  free  route  into  the  hip-joint. 


CHAPTER   XXIX. 

AMPUTATIONS  AND  DISARTICULATIONS. 

The  removal  of  a  limb  or  a  part  of  a  limb  for  injury  or  disease 
is  called  amputation.  The  same  term  is  used  to  designate  the 
operative  removal  of  the  tongue,  penis,  breast,  and  other  accessible 
peripheral  organs  or  parts  of  organs.  Amputation  is  always  a 
mutilating  procedure,  and  a  confession  on  part  of  the  surgeon  that 
the  conditions  necessitating  its  performance  were  beyond  the  limits  of 
conservative  measures  ;  hence  beyond  the  reach  of  restorative  treat- 
ment. 

The  public  always  has  entertained  an  exaggerated  idea  as  to  the 
magnitude  and  importance  of  this  operation,  the  idea  being  shared, 
to  a  considerable  extent,  by  medical  students  and  the  members  of 
the  profession  the  date  of  whose  diplomas  extends  back  to  a  time 
when  conservative  surgery  had  a  very  limited  field  of  usefulness. 
The  removal  of  an  entire  extremity  in  a  few  minutes  by  a  few  dex- 
terous strokes  of  the  knife  has  electrified  many  medical  audiences, 
and  has  been  the  source  of  self-congratulation  and  unenviable  pride 
by  many  operators.  Such  efforts  at  display  of  operative  skill  were 
ju.stifiable  before  anesthetics  came  into  use,  but  are,  fortunately, 
seldom  witnes.sed  at  the  i)re.sent  time.  A.septic  and  anti.septic  sur- 
gery has  enlarged  the  field  of  conservative  surgery,  and  in  the  same 
ratio  has  reduced  the  indications  for  mutilating  operations.  Surgeons 
have  come  to  reali/.e  that,  as  far  as  the  safety  and  best  interests  of 
their  patients  are  concerned,  technical  skill  is  of  minor  importance 
as  compared  with  the  practical  application  of  the  science  of  surgery 
in  determining  when  and  where  to  amputate.  All  other  things 
being  equal,  the  surgeon  who  has  the  smallest  amputation  stati.stics 
is  the  one  who  is  most  useful  and  successful.  A  few  years  ago  an 
amputatirjn  reputation  carried  great  import  in  establishing  surgical 
fame,  but  at  the  present  time  it  has  cea.sed  to  be  regarded  in  so 
favorable  a  light.  The  surgeon  who  can  .save  a  limb  is  entitled  to 
more  credit  than  he  who  r.-m  remove  it  b)'  a  most  brilliant  amputation. 


I060  AMPUTATIONS    AND    DISARTICULATIONS. 

The  greatest  difficulties  the  emergency  surgeon  encounters  in 
his  practice  are  not  the  technical,  but  the  scientific,  demands  made 
upon  him  when  in  charge  of  a  case  in  which  arises  the  question  of 
amputation.  He  feels  his  own  weakness  most  keenly  in  deciding 
upon  when  and  where,  and  not  how,  to  amputate.  It  is  in  deter- 
mining the  legitimate  scientific  indications  for  amputation  that  his 
conscience  and  good  judgment  so  often  dictate  the  necessity  of  a 
consultation.  It  is  in  drawing  the  line  between  a  conservative 
course  of  treatment  and  a  mutilating  operation  that  he  is  so  willing 
and  anxious  to  avail  himself  of  the  advice  of  one  or  more  of  his  col- 
leagues. The  removal  of  a  limb,  except  for  manifestly  clear  indica- 
tions, involves  great  professional  and  legal  responsibilities.  Many 
unpleasant  and  costly  legal  amputations  that  have  figured  so  con- 
spicuously in  the  courts  in  all  parts  of  our  country  might  have  been 
averted  by  timely  and  more  frequent  consultations. 

The  general  practitioner  is  brought  most  frequently  in  contact 
with  the  injured  in  civil  life,  and  upon  the  course  of  treatment  he 
pursues  will  depend  the  fate  of  the  limb.  Under  aseptic  precau- 
tions injuries  that  upon  first  sight  appeared  to  warrant  a  primary 
amputation  often  heal,  while  an  apparently  insignificant  injury, 
carelessly  treated,  may  give  rise  to  complications  endangering 
the  limb  and  even  the  life  of  the  patient.  Antiseptic  surgery  fre- 
quently succeeds  in  dealing  successfully  with  complications 
that  heretofore  were  considered  ample  to  justify  a  mutilating  op- 
eration. 

Indications  for  Amputation. — Every  conscientious  surgeon  is 
anxious  to  formulate  clear  indications  before  resorting  to  the  use  of 
the  knife,  and  this  should  be  more  especially  the  case  in  deciding 
upon  the  propriety  of  performing  an  amputation,  as  this  operation 
must  be  regarded  as  one  of  the  most  mutilating  procedures  in  sur- 
gery. If  the  indications  are  not  sufficiently  clear  to  warrant  ampu- 
tation, the  patient  is  certainly  entitled  to  the  benefit  of  the  doubt. 
Conservative  surgery  has  advanced  sufficiently  to  demand  full 
recognition,  and  should  take  its  proper  high  place  in  the  practice  of 
the  general  practitioner  as  well  as  the  professional  surgeon. 

A  careful  and  systematic  study  of  the  indications  for  amputation 
implies  a  comprehensive  and  an  accurate  knowledge  of  the  nature 
and  extent  of  the  injury,  or  the  pathologic  conditions  that  have 
raised  the  question  of  amputation.  Without  such  knowledge  erro- 
neous conclusions  are  only  too  often  reached,  upon  which  is  based 
the  subsequent  faulty  treatment.  The  indications  for  amputation 
have  been  entirely  recast  during  the  last  three  decades.  The  present 
status  of  surgery  entitles  us  to  the  expectation  that  the  limits  of 
conservative  surgery  will  be  expanded  under  further  improvements 
in  the  treatment  of  injury  and  disease,  and  consequently  that  the 
indications  for  amputation  will  become  still  more  restricted  by  a 
more  nearly  perfect  aseptic  technic  and  improved  methods  of  deal- 
ing with  infective  processes  and  malignant  diseases. 


INDICATION'S    FOR    PRIMARY    AMPUTATION.  I061 

Indications  for  Primary  Amputation. — /.  Extensive  crushing 
of  the  bancs  and  tearing  of  large  vessels  and  nerves.  In  the  section  on 
Compound  Fractures  it  was  distinctly  stated  that  in  such  cases  the  in- 
dications for  a  primary  amputation  were  furnished  rather  by  the  pres- 
ence of  wounds  of  the  large  vessels  and  nerves  than  by  the  extent  of 
the  bone  injury.  Sev-ere  crushing  of  a  limb  with  injur\^of  the  large 
vessels  and  nerves  is  invariably  followed  by  gangrene,  and  always 
warrants  a  primary  amputation  as  soon  as  the  patient  has  recovered 
from  shock.  /;/  such  injuries  conservatism  under  the  strictest  aseptic 
precautions,  to  determine  the  point  where  the  ampiitation  should  be 
made  by  the  formation  of  the  line  of  deniai'catio?i,  is  tinzoarranted,  as 
it  exposes  the  patient  to  great  risks  of  vfection  ivithout  furnishing  a 
sufft.cient  compensation  in  the  possible  iticreascd  length  of  the  stump. 
Any  injury  that  permanently  suspends  nutrition  at  and  beloiv  the  wound 
justifies  a  primary  ajiiputation. 

2.  Exte7isive  tearing  and  crushing  of  skin  and  muscles  with  slight 
or  no  bone  injury.  Such  wounds  are  most  frequently  caused  by 
machinery  accidents.  Conservative  surgery  can  be  carried  too  far 
in  these  cases  also,  as  even  in  the  event  of  a  final  recovery  after  a 
resort  to  plastic  operations  or  skin-grafting,  the  limb  is  worse  than 
useless,  and  is  amputated  later  on  the  urgent  request  of  the  patient. 
The  tdtimate  practical  result  must  be  taken  into  consideration  i^i  de- 
cidijig  between  primary  amputation  and  a  conservative  course  of  treat- 
7nent. 

Extensive  decortication  alone  may  become  a  sufficient  cause  for 
ampuUition.  In  a  case  of  this  kind  I  succeeded,  by  a  primary  plastic 
operation,  in  preserving  a  useful  foot.  The  patient  was  a  girl  ten 
years  of  age,  who  sustained  a  street-car  injury.  The  toes  were 
crushed,  and  the  skin  was  torn  away  as  far  as  Chopart's  joint. 
Amputation  through  this  joint  would  have  resulted  in  a  wound  that 
could  not  have  been  covered  throughout  by  skin.  For  the  purpo.se 
of  saving  the  foot,  a  plastic  operation  was  performed,  probably  the 
first  one  of  the  kind.  It  was  found  that  by  flexing  thigh  and  knee 
and  turning  the  limb  inward,  the  sole  of  the  foot  could  be  brought 
in  contact  with  the  anterior  surface  of  the  abdomen.  Under  strict 
aseptic  precautions  a  pocket  was  made  in  the  skin  below  the 
umbilicus,  large  enough  to  receive  the  denuded  part  of  the  foot. 
The  edges  of  the  torn  skin  were  carefully  trimmed  and  sutured  to 
the  margins  of  the  wound  all  around.  The  crushed  toes  were 
brought  through  an  inci.sion  at  the  base  of  the  pocket,  the  same 
opening  being  utilized  for  drainage.  The  wound  was  dres.scd  in 
such  a  way  that  the  whole  foot  and  anterior  surface  of  the  abdominal 
wall  were  included  in  the  dressing,  the  limb  and  trunk  being  im- 
mobilized by  a  light  pla.ster-of- Paris  dressing.  It  was  expected  that 
this  awkward  po.sition  of  the  limb  would  become  unbearable  to  the 
little  patient,  but  in  this  we  were  [jleasantiy  di.sappointed.  The  child 
was  restless  only  for  the  first  two  days,  and  perfectly  satisfied  and 
comfortable  the  remainder  of  the  time.      The  wound  healed  rajudly. 


I062  AMPUTATIONS    AND    DISARTICULATIONS. 

and  in  two  weeks  the  skin,  which  was  firmly  attached  to  the  dorsal 
surface,  was  detached,  including  enough  on  each  side  to  cover  the 
plantar  surface.  This  circular  flap  furnished  an  excellent  substitute 
for  the  skin  lost  by  the  accident,  and  the  patient  recovered  with  a 
very  useful  foot,  minus  the  crushed  toes. 

As  substitutes  for  amputation,  whole  or  in  part,  primary  plastic 
operations  of  this  kind  will  prove  of  the  greatest  value  in  injuries  of 
the  fingers  and  hands. 

Indications  for  Secondary  Amputation. — As  much,  or  perhaps 
even  more,  has  been  achieved  by  the  advancements  made  by  modern 
surgery  to  restrict  secondary  amputations  as  in  limiting  the  indica- 
tions for  primary  amputation.  The  pride  of  the  surgeon  of  to-day 
consists  in  adopting,  in  appropriate  cases,  conservative  measures, 
and  in  carrying  them  to  the  utmost  limits,  in  the  place  of  mutilating 
operations  in  the  treatment  of  injuries  and  disease.  Secondary 
amputations  have  become  less  and  less  frequent,  owing  to  two 
principal  causes,  viz. : 

/.  Aseptic  precautions  have  succeeded  in  greatly  diminishing  the 
frequency  of,  if  not  entirely  preventing,  wound  infection  and  its  com- 
plications, which  formerly  so  often  made  amputation  imperative  as  a 
life-saving  operation. 

2.  Antiseptic  surgery  deals  successfully  with  a  large  percentage  of 
suppurative  affections  that  formerly  were  Jiot  zvithin  the  reach  of  suc- 
cessfid  conservative  treatment. 

1.  Gangrene  foWowing  injury  or  as  a  remote  result  of  pathologic 
conditions  that  ultimately  suspend  nutrition  always  constitutes  a 
well-founded  indication  for  amputation.  While  there  can  be  no  dif- 
ference of  opinion  regarding  the  significance  of  gangrene  as  a  cause 
for  amputation,  the  question  as  to  where  and  when  to  amputate  is 
often  not  so  easy  to  decide. 

In  amputations  for  traumatic  gangrene  operative  interfere^tce  must 
be  resorted  to  promptly  when  the  sepsis  attending  it  endangers  the  life 
of  the  patient,  and  after  the  most  energetic  antiseptic  treatment  has 
failed.  The  amputation  must  be  made  through  healthy  tissue  and  at 
a  point  where  the  principal  blood-vessels  are  permeable,  hi  gangrene 
unattended  by  symptoms  indicative  of  the  existence  of  sepsis  sufficient 
in  severity  to  constitute  a  source  of  danger  to  life,  it  is  wisdom  on  the 
part  of  the  surgeon  to  postpone  the  amputation  until  the  line  of  demarc- 
ation is  well  established,  as  this  furnishes  the  most  reliable  guide  in 
deciding  where  to  amputate. 

2.  Septicopyemia,  so  frequent  a  cause  for  amputation  until  re- 
cently, is  seldom  seen  at  the  present  time  sufficient  in  severity  to 
justify  amputation.  Free  incisions,  efficient  drainage,  continuous 
antiseptic  irrigation,  and  the  internal  administration  of  heroic  doses 
of  alcohol  have  shown  themselves  to  be  such  powerful  weapons  in 
the  hands  of  the  surgeon  that  amputation  as  a  life-saving  operation 
is  reserved  for  exceptional  cases.  It  is  proper  to  amputate  in  cases 
in  which  the  vigorous  conservative  measures  fail   in  arresting  the 


NONTRAUMATIC    PATHOLOGIC    CONDITIONS.  1063 

septic  infection.  In  cases  of  well-developed  pyemia  it  is  doubtful 
if  an  amputation  as  a  life-saving  resource  will  accomplish  more  than 
energetic  antiseptic  treatment  of  the  infected  wound. 

^  J.  Prolonged  exhm/sfiiig  suppuration  continues  to  furnish  a  cer- 
tain number  of  well-selected  cases  for  amputation.  Amputation  for 
such  an  indication  becomes  necessary  most  frequently  in  extensive 
tuberculosis  of  bones  and  joints,  complicated  by  mixed  infection 
with  pus-microbes  and  the  formation  of  large  and  deep  abscesses, 
more  especiall\-  in  adults  and  persons  advanced  in  years.  But  even 
under  such  circumstances  amputation  is  becoming  less  frequently  a 
necessity,  as  treatment  by  laying  open  the  abscess  cavity  from  end 
to  end,  or.  if  this  can  not  be  done  for  anatomic  reasons,  by  multiple 
large  incisions  followed  by  curettage,  antiseptic  irrigation,  iodoform 
gauze  tamponade,  and  partial  suturing  of  the  wound,  very  often  suc- 
ceeds in  saving  the  life  and  limb  of  the  patient.  Amputation  cer- 
tainly should  not  be  entertained  until  such  treatment  has  proved 
unsuccessful. 

Indications  for  Amputation  by  Nontraumatic  Pathologic 
Conditions. — The  nontraumatic  pathologic  conditions  that  warrant 
amputation  are  clinically  characterized  by  their  progressive  tenden- 
cies and  their  obstinacy  to  less  severe  local  treatment.  They  are  cases 
that  do  not  require  immediate  action,  and  can  be  studied  at  length 
and  in  a  most  thorough  manner  as  to  their  nature  and  the  necessity 
for  radical  treatment  by  amputation.  Moreover,  they  are  cases  in 
which  it  is  easier  to  decide  where  and  when  to  perform  the  opera- 
tion. 

/.  Extensive  destruetion  of  the  skin  does  not  so  often  warrant 
amputation  since  the  general  use  of  methods  of  skin-grafting  de- 
vised by  Reverdin,  Thiersch,  Wolfe,  and  Hirschberg.  But  there 
are  cases  of  circular  ulcer  of  the  leg  of  long  standing,  and  attended 
by  grave  pathologic  conditions  above  and  below  the  seat  of  ulcera- 
tion, in  which  amputation  is  not  only  justifiable,  but  positively  indi- 
cated. The  temporary  results  of  .skin-grafting  in  such  instances  are 
often  lost  very  soon  after  the  patient  leaves  his  bed  ;  besides,  there 
is  always  considerable  danger  of  such  ulcers  becoming  the  .starting- 
point  of  carcinoma.  Ami)utation,  however,  becomes  a  justifiable 
treatment  only  after  conservative  resources,  such  as  rest  in  bed  with 
the  limb  in  an  elevated  position,  warm  aseptic  compresses,  skin- 
grafting,  and  the  elastic  webbing  bandage,  have  had  a  fair  trial. 

2.  Gangrene  resulting  from  causes  other  than  trauma  and  its 
complications  usually  necessitates  amputation  sooner  or  later.  Senile 
and  diabetic  gangrene  furnish  the  largest  number  of  cases.  Throm- 
bosis and  embolism  of  the  principal  blood-vcs.sels  constitute  other 
prolific  causes  of  gangrene  of  the  lower  extremities,  especially  in 
the  aged,  the  subjects  of  advanced  arterial  atheroma.  Gangrene 
from  exccs.sive  heat  and  cold,  burns,  and  frr^t-bites  is  most  {cc- 
quently  met  with  in  the  young  and  vigorous,  actively  engaged  in 
the  pursuits  of  life. 


1064  AMPUTATIONS    AND    DISARTICULATIONS. 

From  a  practical  standpoint  it  is  important  to  distinguish  between 
dry  and  moist  gangrene.  In  dry  or  aseptic  gangrene  life  is  not  endan- 
gered by  the  local  cause,  and  operative  interference  is  never  justifiable 
until  the  line  of  demarcation  has  become  well  defined,  showing  the  boun- 
dary-line  between  living  and  dead  tissue.  It  is  in  such  instances  that 
the  surgeon  often  steps  in  and  completes  the  task  undertaken  by  the 
living  tissues  by  limiting  the  use  of  his  instruments  to  the  removal 
of  dead  tissue,  permitting  the  resulting  wound  to  heal  by  granula- 
tion. In  moist  gangrene  this  ride  has  many  exceptions.  Amputation 
for  moist  gangrene  becomes  an  urgent  necessity  ivhen  the  gangrene  is 
progressive  and  attended  by  increasing  sepsis.  If  in  such  cases  the 
surgeon  awaits  the  appearance  of  the  line  of  demarcation  as  a  sig- 
nal for  the  operation  to  be  performed,  he  will  look  for  something 
never  to  be  realized,  such  patients  dying  from  sepsis.  An  early 
operation  in  the  right  place  is  urgently  indicated  not  so  much  to 
remove  the  dead  tissues  as  to  get  rid  of  the  septic  material  that 
they  contain,  which  finds  its  way  into  the  general  circulation,  becom- 
ing the  direct  cause  of  death.  In  other  words,  the  operation  is 
performed  to  remove  the  source  of  the  septic  infection. 

In  selecting  the  site  for  the  operation  the  surgeon  must  satisfy 
himself  of  the  permeability  of  the  principal  arteries  at  the  proposed 
line  of  amputation,  and  if  he  finds,  on  performing  the  operation, 
that  he  was  mistaken  in  this  respect,  he  must  seek  a  higher  level. 
For  this  reason  it  is  advisable  to  make  the  first  incision  in  the  side 
of  the  limb  where  the  large  blood-vessels  are  located,  in  order  to 
determine  their  condition  before  completing  the  operation.  It  is  in 
moist  gangrene  that  thrombosis  is  so  liable  to  proceed  rapidly  in  the 
direction  of  the  body,  and  below  the  common  femoral  artery  it  is 
not  always  possible  to  determine  beforehand  whether  or  not  the 
principal  blood-vessels  are  permeable.  In  gangrene  following  em- 
bolism the  line  of  amputation  must  always  cross  the  affected  vessel 
above  the  level  of  the  embolus,  as  thrombosis  in  a  proximal  direc- 
tion often  proceeds  very  rapidly  after  the  impaction  of  the  embolus. 
In  embolism  of  the  popliteal  artery  at  its  bifurcation  the  proximal 
thrombus  often  extends  several  inches  above  the  embolus. 

Malignant  Tumors. — With  the  exception  of  limited  malignant 
disease  of  the  skin,  carcinoma  and  sarcoma  of  the  extremities  de- 
mand early  operative  treatment  by  amputation.  The  frequency  zvith 
which  recurrence  in  the  axillary  and  ingidnal  regions  takes  place  after 
amputation  for  carcinoma  has  led  surgeons  to  the  conclusion  that  those 
spaces  sJioidd  be  thoroughly  cleared  out  before  or  after  the  operation, 
m  the  same  manner  and  for  the  same  reasons  as  the  axillary  space  is 
cleared  out  in  all  operations  for  carcinoma  of  the  mammary  gland,  and 
this  regardless  of  the  condition  of  the  lymphatic  glands.  This,  how- 
ever, is  not  done  so  constantly  and  so  thoroughly  as  it  should  be, 
and  a  lack  of  proper  precaution  in  this  direction  is  responsible  for 
many  recurrences,  early  and  late,  that  might  have  been  prevented. 
Judging  from  the  experience  of  the  past,  if  a  carcinoma  of  the  skin 


GENERAL  TECHNIC  OF  AMPUTATION.  I065 

has  extended  beyond  the  subcutaneous  connective  tissue,  the  pros- 
pects of  a  local  operation  are  anything  but  encouraging.  In  the 
great  majority  of  such  cases  amputation  is  the  only  treatment  that 
offers  any  hope  of  a  permanent  result. 

Sarcoma  of  the  periosteum  and  bone,  when  the  diagnosis  has 
once  been  established  beyond  all  doubt,  justifies  treatment  by  ampu- 
tation. A  few  cases  have  recently  been  reported  in  which  it  is 
alleged  that  in  myeloid  sarcoma  of  the  epiphyseal  extremity  of  the 
long  bones  permanent  results  have  been  obtained  by  exposing  the 
tumor  and  removing  it  by  the  vigorous  use  of  a  sharp  spoon.  While 
such  treatment  might  appear  justifiable  in  cases  in  which  an  early 
diagnosis  is  made,  the  patient  should  be  informed  of  the  uncertainty 
of  the  result,  and,  on  the  appearance  of  the  first  evidences  of  a  re- 
currence, amputation  must  be  promptly  performed.  As  a  rule,  to 
which,  however,  there  are  exceptions,  the  amputation  should  in- 
clude the  whole  affected  bone.  The  exceptions  present  themselves 
most  frequently  in  sarcoma  of  the  lower  end  of  the  femur,  where  a 
high  amputation  of  the  thigh  is  attended  by  much  less  risk  to  life 
than  a  disarticulation  through  the  hip-joint. 

Atrophic,  deformed,  paralytic;  useless  limbs,  in  a  condition  not 
amenable  to  restoration  of  function  by  orthopedic  treatment  and 
appliances,  often  become  an  incumbrance  to  the  patient  and  an  am- 
putation may  be  justifiable  if  the  patient  makes  an  urgent  request 
to  that  effect. 

General  Technic  of  Amputation, — Site  of  Operation.  —  A 
modern  amputation  has  in  view  not  only  the  removal  of  dead  tissue, 
— sources  of  infection  that  threaten  life  and  are  beyond  the  reach 
of  more  conservative  treatment,  malignant  tumors  of  the  extremities, 
limbs  that  are  useless  and  a  burden  to  the  patient, — but  also  the 
securing  of  a  painless,  useful  stump.  This  last  object  of  the  oper- 
ation often  comes  in  conflict  with  the  pathologic  indications  that 
demand  the  operation.  Another,  but  less  important,  consider- 
ation in  deciding  upon  the  method  of  operating  is  the  cosmetic 
result,  which  applies  more  particularly  to  amputations  of  the  upper 
extremity  below  the  wrist-joint. 

Aside  from  the  pathologic  indications,  the  functional  result  de- 
mands the  first  con.sideration.  Ihis  can  be  best  ill  u.strated  by  injury 
or  di.sease  of  the  ankle-joint  and  tarsus  necessitating  amputation. 
The  pathologic  indications  may  be  fully  met  by  Syme's  amputation 
through  the  ankle-jfjint,  but  the  resulting  stump  would  be  far  less 
useful  to  the  patient  than  if  the  amputation  had  been  made  at  the 
point  of  selection — that  is,  at  the  junction  of  the  middle  and  lower 
third  of  the  leg.  The  old  teaching  that  the  amputation  should  be 
made  as  far  away  from  the  body  as  is  compatible  with  the  complete 
removal  of  di.seased  tissue  has  undergone  many  changes  in  conse- 
quence of  improved  methods  of  wound  treatment  and  the  additional 
duty  recently  imposed  upon  the  surgeon  to  secure  for  the  [)atient  a 
painless,  u.seful  stump.      It  was  formerly  claimed,  and  perhaps  with 


I066  AMPUTATIONS    AND    DISARTICULATIONS. 

good  reason,  that  the  danger  of  an  amputation  to  the  hfe  of  the 
patient  increases  with  the  approach  of  the  operation  toward  the 
trunk.  This  argument  has  lost  its  force  since  anesthesia,  improved 
hemostasis,  and  asepsis  have  come  into  general  use.  It  still  holds 
good  in  amputations  of  the  upper  part  of  the  thigh,  however,  as  a 
subtrochanteric  amputation  of  the  thigh  is  attended  by  much  less 
immediate  risk  to  life  than  disarticulation  at  the  hip-joint.  It  is 
entirely  different  in  amputations  through  the  lower  part  of  the  leg, 
ankle-joint,  and  tarsus.  All  things  being  equal,  an  amputation  at 
the  point  of  election  at  the  junction  of  the  middle  with  the  lower 
third  of  the  leg  is  not  attended  by  more  immediate  or  remote  danger 
to  life  than  an  amputation  through  the  ankle-joint.  Moreover,  it 
yields  an  ideal  stump  for  the  wearing  of  an  artificial  limb,  while  the 
reputation  of  every  instrument  maker  is  at  stake  who  provides  an 
artificial  limb  for  a  patient  who  has  undergone  Syme's  amputation. 

For  the  purpose  of  niinijnizing  the  immediate  risks  to  life,  amputa- 
tions at  the  base  of  the  thigh  should  be  performed  below  the  Jiipfoint 
in  all  cases  in  which  such  a  course  is  compatible  with  the  pathologic 
indications. 

On  the  other  hand,  in  all  amputations  below  the  base  of  the  thigh 
the  functional  result  must  be  taken  into  serious  consideration  in  deter- 
mining upon  the  site  of  the  operation.  Disarticulation  at  the  knee- 
joint  has  but  few  advocates  at  the  present  time  because  the  resulting 
stump  is  bulbous  and  ill  adapted  for  the  wearing  of  an  artificial  limb. 
In  amputations  through  the  upper  part  of  the  leg  it  must  not  be 
forgotten  that  a  stump  four  inches  long  is  the  shortest  one  that 
enables  the  patient  to  wear  an  artificial  limb.  It  is  such  a  stump, 
too,  that  will  be  most  serviceable  in  wearing  a  peg-leg,  which, 
among  the  poorer  classes,  is  largely  depended  upon  for  locomotion. 
If  an  amputation  has  to  be  done  above  this  level,  the  next  point  of 
selection  is  through  the  base  of  the  condyles.  For  this  operation  the 
surgeon  should  select  the  Gritti- Stokes'  transcondyloid  osteoplastic 
amputation,  which  yields  an  ideal  conic  stump,  well  fitted  for  the 
wearing  of  an  artificial  limb.  Whenever  admissible,  in  all  amputa- 
tions of  the  lower  extremit)^  above  the  ankle-joint,  the  operation 
should  be  made  at  a  point  and  in  such  a  manner  as  to  secure  a  conic 
stump,  so  keenly  appreciated  by  every  manufacturer  of  artificial 
limbs,  and  subsequently  by  the  patient.  It  must  be  remembered 
that  when  the  patient  comes  to  wear  an  artificial  limb,  the  weight 
of  the  body  should  not  fall  upon  the  end  of  the  stump,  but  upon  its 
sides,  something  that  can  be  fully  and  satisfactorily  accomplished 
only  if  the  shape  of  the  stump  is  conic. 

Amputation  Neuroma. — Every  surgeon  is  familiar  with  the  fact 
that  the  most  frequent  cause  of  painful  stumps  is  the  so-called  am- 
putation neuroma,  a  bulbous  enlargement  of  the  cut  end  of  the 
principal  nerves.  This  painful  remote  complication  of  amputation 
always  develops  in  the  scar  tissue  of  the  wound,  in  which  it  is  in- 
variably found  embedded.     The  most  effective  prophylactic  measure 


AMPUTATION  NEUROMA.  I067 

against  the  development  of  such  a  condition  consists  in  exsection 
of  an  inch  or  two  of  the  principal  nerves  in  the  amputation  wound, 
in  this  manner  protecting  the  nerve-ends  against  irritation  by  the 
scar  tissue. 

Neuroma  as  a  remote  complication  of  amputation  appears  in 
the  form  of  a  bulbous  enlargement  of  the  end  of  the  principal 
nerve  or  nerves  in  the  stump.  Such  a  tumor  usually  makes  its 
appearance  a  (ew  weeks  or  months  after  the  operation,  and 
is  the  most  frequent  cause  of  painful  stumps.  The  usually 
accepted  theory  attributes  the  enlargement  of  a  nerve-end  in 
amputation  neuroma  to  an  abundant  formation  of  small  myelinic 
fibers  produced  from  the  neuroblasts  that  have  been  exposed  for  a 
long  time  to  irritation  caused  by  cicatricial  tissue.  It  is  well  known 
that  an  amputation  neuroma  will  develop  only  in  connection  with 
scar  tissue  and  the  irritation  incident  to  the  condition  producing  it. 
Eveiy  amputation  neuroma  will  be  found  embedded  in  more  or  less 
of  scar  tissue.  Witzel  has  recenth^  shown  that  in  many  cases  the 
neuroma  is  found  attached  to  the  end  of  the  bone  in  the  stump.  It 
is  more  than  probable  that  the  cut  ends  of  the  nerve-fibers  become 
attached  to  the  scar  tissue,  which  acts  the  part  of  a  foreign  sub- 
stance and  excites  the  active  and  abnormal  tissue  proliferation,  upon 
which  depends  the  formation  of  the  neuroma.  The  tumor  presents 
itself  in  the  form  of  a  bulbous  enlargement  of  the  end  of  the  nerve, 
which  closely  resembles  a  spring  onion  in  outline.  Cross-sections 
of  such  tumors  show  the  numeric  increase  of  myelinic  nerve-fibers. 
Nicoladoni's  assistant  has  made  some  very  interesting  investigations 
regarding  the  structure  of  amputation  neuroma,  and  has  come  to  the 
conclusion  that  the  numeric  increase  of  nerve-fibers  is  apparent,  and 
not  real.  According  to  his  observations,  the  increase  is  due  to 
the  formation  of  loops  growing  out  of  the  elongation  of  the  pre- 
existing fibers. 

Virchow  called  attention  to  such  a  possibility  years  ago,  and 
emphasized  particularly  the  difficulty  in  following  out  and  tracing 
the  nerve-fibers.  It  is  very  desirable  that  future  research  should 
settle  this  question  definitel)'.  With  the  poliferation  or  growth  of 
the  nerve-fibers  the  interstitial  connective  tissue  is  increased  under 
the  same  influence,  the  resulting  tumor  constituting  histologically  a 
true  neurofibroma. 

Within  a  short  time  the  tumor,  as  a  rule,  reaches  its  maximum 
size,  seldom  exceeding  twice  the  circumference  of  the  nerve-trunk, 
when  it  becomes  stationary  and  manifests  little  or  no  tendency  to 
degenerative  processes.  In  the  majority  of  cases  the  tumor  is 
limited  and  forms  the  bulbous  extremity  of  the  nerve  ;  in  some 
instances,  as  in  the  ca.se  reported  by  Ilayem  and  Gilbert,  the  nerve 
is  at  the  .same  time  enlarged  for  a  considerable  di.stance  above  the 
tumor,  the  enlargement  being  due  to  an  abundant  formation  of  inter- 
stitial connective  tissue.  Every  surgeon  of  large  experience  knows 
that  an  amputation  neuroma  in  some  ca.ses  is  exceedingly  prone  to 


io68 


AMPUTATIONS    AND    DISARTICULATIONS. 


return  after  excision,  and  these  are  undoubtedly  the  cases  in  which 
the  nerve  is  enlarged  far  beyond  the  bulbous  extremity.  I  have 
known  instances  in  which  such  neuromata  were  excised  four  or  five 
times,  and  an  early  return  of  the  pain,  with  recurrence  of  the  tumor, 
followed  each  operation.  In  one  case  a  cure  was  finally  effected  by 
excising  four  inches  of  the  sciatic  nerve,  far  beyond  the  apparent 
limits  of  the  tumor  and  enlargement  of  the  nerve.  Neuroma  is 
more  apt  to  appear  in  persons  the  subjects  of  an  inherited  or  acquired 
predisposition  to  the  active  proliferation  of  the  elements  of  which  a 
nerve  is  composed,  more  especially  the  presence  in  the  injured  nerve 
of  an  abnormal  abundance  of  potential  neuroblasts. 

Virchow,  in  speaking  of  the  etiology  of  neuromata,  very  properly 
alludes  to  such  a  general  aptitude,  which  he  terms  neuroblasty,  or 
neuromatosis.  A  surgeon  performs  two  amputations  for  the  same 
conditions  and  under  the  same  circumstances,  following  the  same 
technic  and  dealing  with  the  same  structures  :  in  one  the  nerve-ends 
become  implicated  ;  in  the  other  they  escape.  The  one  who  subse- 
quently suffers  from  neuroma  must  necessarily 
have  furnished  the  essential  conditions  for  the 
development  of  this  remote  complication, 
which  were  inadequate  or  absent  in  the  other. 
Amputation  neuroma  has  become  less  frequent 
since  surgeons  have  become  aware  of  the  fact 
that  the  exciting  cause  is  always  scar  tissue 
formed  around  the  end  of  the  cut  nerve.  Ex- 
cising the  principal  nerves  a  considerable  dis- 
tance above  the  level  of  the  wound  and  primary 
wound  healing  under  aseptic  precautions  have 
succeeded  in  diminishing  the  frequency,  but 
not  in  preventing  with  certainty  the  occur- 
rence, of  neuroma  after  amputation.  Ampu- 
tation neuroma  will  continue  to  appear  in  the  practice  of  the  most 
careful  and  painstaking  surgeons.  The  frequency  with  which  such 
tumors  recur  after  ordinary  excision  as  generally  practised  is  well 
known. 

I  have  seen  a  number  of  such  cases  in  which  excision  was  per- 
formed from  four  to  six  times  by  different  operators,  all  without 
permanent  relief.  For  nearly  three  years  I  have  adopted  a  method 
of  excision  that  has  proved  eminently  successful  in  preventing  recur- 
rence. This  procedure  proved  permanently  satisfactory  in  several 
instances  in  which  repeated  excision  had  been  followed  by  speedy 
recurrences.  Recognizing  the  fact  that  neuroma  after  amputation 
always  develops  in  connection  with  scar  tissue  and  is  undoubtedly 
the  result  of  irritation  of  the  cut  ends  of  the  fibers  incorporated  in 
the  scar  tissue,  I  was  induced  to  excise  the  nerve  at  a  safe  distance 
from  the  tumor  in  a  manner  that  would  prevent  such  an  occurrence. 
This  I  accomplished  by  bringing  the  cut  ends  of  the  nerve-fibers  in 
contact  and  by  interposing  between  them  and  the  scar  tissue  the 


Fig.  606.  —  Opera- 
tion for  the  prevention 
and  cure  of  amputation 
neuroma. 


AMPUTATION  NEUROMA.  IO69 

normal  covering  of  the  nerve — the  nerve  sheath.  After  dissecting 
up  the  scar  tissue  in  connection  with  the  neuroma,  the  nerve  is  hber- 
ated  to  the  requisite  extent  and  excised  at  a  safe  distance  from  the 
tumor  by  making  a  V-shaped  incision,  forming  a  wedge  on  the  part 
of  the  nerve  removed  and  two  small  flaps  on  the  proximal  end. 
These  little  flaps,  according  to  the  size  of  the  nerve,  are  brought 
together  by  from  one  to  three  fine  catgut  sutures,  giving  the  nerve- 
end  a  conic  shape.  In  nerves  of  the  size  of  the  median,  ulnar,  and 
musculospiral,  one  suture  at  the  apex  of  the  cone  answers  the  pur- 
pose. In  operations  on  the  sciatic  nerve  one  terminal  and  two  lat- 
eral sutures  are  necessary.  This  method  of  nerve  resection  furnishes 
absolute  protection  to  the  nerve-fibers  against  irritation  on  the  part 
of  scar  tissue,  and  interposes  between  the  nerve-fibers  and  the  scar 
tissue  resulting  from  the  operation  the  normal  protection  of  the 
nerve — the  nerve  sheath.  Should  it  become  necessary  to  operate 
on  two  nerves  in  close  proximity,  the  same  object  is  obtained  by 
suturing  the  nerve-ends  together  after  excision  of  the  neuromata. 
As  an  additional  precaution  the  nerve-end  can  further  be  protected 
by  covering  it  with  adjacent  muscle  tissue  by  a  few  points  of  buried 
absorbable  sutures  before  closing  the  external  wound. 

No  amputation  above  the  ankle-  and  the  ivrist-joint  is  complete 
•zvithont  primary  exsection  of  the  principal  nerve -trunks  in  the  a^nptita- 
tion  wound.  In  amputations  of  the  tipper  extrennty,  the  highest  degree 
of  conservatism  must  govern  the  surgeon  in  planfiing  and  executiiig  a 
mutUating  operation.  Every  inch,  and  every  fraction  of  an  inch,  of 
tissue  that  can  be  saved  will  enhance  the  functional  result.  Cos- 
metic considerations  can  be  entertained  only  in  operating  upon  per- 
sons of  wealth  ;  they  are  out  of  question  in  practice  among  the 
laboring  people.  It  is  seldom  necessary  to  amputate  a  finger  for 
osteomyelitic  affections,  as  extraction  of  sequestra  and  resection  of 
joints  will  often  be  rewarded  by  a  useful  finger,  though  shortened 
and  perhaps  stiff.  The  recuperative  power  of  the  tissues  of  the  fin- 
gers and  hands  is  something  marvelous,  and  will  often  result  in 
repair  of  traumatic  and  pathologic  defects  that  at  first  appeared 
almost  hopeless.  A  straight  stiff  finger  is  useless  and  often  an  in- 
cumbrance ;  hence  if  such  a  condition  is  anticipated,  tlie  injured  or 
diseased  finger  must  be  placed  and  held  in  proper  position  by  an 
appropriate  mechanical  support  during  the  whole  time  required  for 
the  completion  of  the  healing  process.  The  finger  mu.st  be  immo- 
bilized in  a  flexed  position,  which  will  aid  and  not  interfere  with  the 
grasping  power  of  the  hand.  Limited  continuous  defects  of  the 
finger  and  hand  can  be  treated  by  a  plastic  operation  or  skin-graft- 
ing with  a  view  to  securing  a  maximum  functional  result,  thus 
limiting  amputation  to  parts  hopelessly  injured  or  di.seased. 

The  surgery  of  the  fingers  and  hands  requires,  on  the  part  of 
the  surgeon,  good  judgment  ami  originality  in  devi.sing  operations 
that  will  meet  the  indications  of  each  individual  ca.se.  Fol- 
lowing blindly  any  text-book  is  dangerous  here,  as  elsewhere,  as 


lO/O 


AMPUTATIONS    AND    DISARTICULATIONS. 


it  often  leads  to  unnecessary  sacrifice  of  tissue  that  could  be  utilized 
in  maintaining  to  a  greater  extent  the  prehensile  power  of  the  hand. 
As  much  of  the  bony  framework  of  the  hand  should  be  saved  as 
possible,  as  a  great  deal  can  be  accomplished  at  once  or  later  in  re- 
storing soft  parts  by  plastic  operation  or  skin-grafting.  In  amputa- 
tions above  the  wrist-joint  the  surgeon  can  take  more  liberty  in  the 
selection  of  the  site  of  operation,  as  the  functional  utility  of  the  stump 
here  is  not  always  proportionate  to  its  length. 

Preparations  for  Operation. — Primary  amputations  are  always 
emergency  operations,  and  must  often  be  performed  hastily  and  with 
limited  assistance  and  facilities.      Too  much  haste,  however,  must 


Fig.  607. — Langenbeck's  metacarpal  saw. 


Fig.  609. — Parker's  capital  saw. 

be  scrupulously  avoided,  and  enough  time  must  be  devoted  in 
making  the  necessary  preparations.  In  amputations  for  disease  the 
usual  painstaking  preparations  for  an  aseptic  operation  must  always 
be  carried  out,  as  time  in  such  instances  does  not  play  so  important 
a  role  as  in  operations  for  injury  of  sufficient  gravity  to  demand  an 
operation.  The  surgeon  frequently  finds  himself  in  a  position  where 
he  must  perform  the  operation  without  skilled  assistance.  Under 
such  circumstances  he  attends  to  the  sterilization  of  the  instruments 
m  person,  prepares  the  antiseptic  and  salt  solutions,  and  attends  to 
the  dressing  material.  He  also  administers  the  anesthetic,  instruct- 
ing the  person  upon  whom  he  can  place  the  most  reliance  how  to 


PREPARATIONS  FOR  OPERATION. 


IO7I 


maintain  the  anesthesia,  and  assigning  to  another  the  task  of 
holding  the  hmb,  and  later  the  stump  during  the  operation.  The 
latter  assistant  is  cautioned  never  to  touch  the  wound  or  the  field 
of  operation.  After  the  patient  is  anesthetized,  the  surgeon  disin- 
fects the  field  of  operation  in  the  manner  described  in  detail  else- 
where, and  during  the  operation,  after  the  hands  have  been  disinfected 


l«y[.«i«L-!*^ 


Fig.  610.— Mathieu's  multiple  point  bone-holding  forceps. 

once  more,  he  takes  the  instrument  from  the  tray  or  sterile  towel, 
and  attends  to  the  sponging  and  ligation  of  vessels  himself 

Any  amputation  can  be  performed  by  the  aid  of  a  few  instru- 
ments :  all  that  is  required  is  a  scalpel,  half  a  dozen  hemostatic  for- 
ceps, a  periosteal  elevator,  scissors,  saw,  bone-forceps,  needles, 
suturing  and  ligature  material,  and  an  elastic  constrictor.  The 
old-fashioned  amputating  knives  are  seldom  seen  in  the  operating 
A  g  room    since    trans- 

fixion    has     been 
largely  abandoned. 
A  stout  scalpel  of 
large  size  is  the  in- 
strument of  choice 
in  dividing  the  soft 
tissues  in  all  major 
amputations,  and  a 
smaller      one      for 
amputation   of  the 
fingers     and     toes. 
K  o  c  h  e  r'  s     artery 
forceps  is   the   one 
best     adapted     for 
grasping  the  blood- 
vessels,     and      for 
seizing    and    draw- 
ing     forward     tlie 
ncrvc-entls  in  mak- 
ing   primary   neur- 
ectomy as  a  prophylactic  against  the  formation  of  amputation  neu- 
roma.     Windler's  or  Butcher's  saw  is  a  better  instrument  than  the 
ordinary  more  cumbersome  amputation  saw  ;  the  small  metacarpal 
.saw  is  be.st  adapted  for  dividing  the   jjlialanges  of  the  fingers  and 
toes.      A  meditmi-sized   .straight  bone-cutting  forceps  is  all  that  is 
required   for  the   trimming  of  the  sawn  end  of  the   bone.      Large 


Fij^.  611. — (jauze  retractors:   A,  For  one  hone 
l)one.s. 


I>,  for  two 


1072 


AMPUTATIONS    AND    DISARTICULATIONS. 


curved  needles  are  used  for  the  deep  sutures,  and  glover's  needles 
for  suturing  the  flaps.  Rubber  drains  of  different  sizes  are  to  be 
kept  on  hand,  and  are  to  be  employed  as  indicated  by  the  condi- 
tion.    The  retractors  are  made  of  sterile  gauze. 

During  the  operation  the  surgeon  takes  a  position  that  will  afford 
him  the  easiest  access  to  the  field  of  operation — usually  in  such  a 
way  that  the  amputated  limb  will  fall  toward  his  right  side. 

Flap  Formation. — In  amputation  for  dry  gangrene  after  the  line 
of  demarcation  has  been  well  established  and  the  dead  tissues  have 
become  partly  separated  from  the  living  by  a  wall  of  granulations, 
the  amputation  is  often  completed  with  little  or  no  use  of  the  knife. 
After  the  bone  or  bones  have  been  reached  all  around,  the  perios- 
teum is  separated  in  the  form  of  a  cuff  by  means  of  an  elevator, 
while  the  soft  tissues  are  retracted.  The  amputation  is  completed 
by  the  use  of  the  saw,  dividing  the  bone  sufficiently  far  above  the 
line  of  demarcation  to  permit  its  face  being  completely  covered  by 
the  periosteal  cuff 


Fig.  612. — Reflection  of  periosteal  cuff  (von  Esmarch). 


An  amputation  under  such  conditions  does  not  require  prophy- 
lactic hemostasis  by  the  elastic  constriction,  as  but  very  little  blood 
is  lost  during  the  operation,  which  aims  to  do  as  little  violence  as 
possible  to  the  living  soft  tissues.  Under  all  other  circumstances 
the  elastic  constrictor  is  relied  upon  in  preventing  loss  of  blood 
during  the  operation.  Some  care  is  necessary  in  applying  the  elastic 
constrictor  as  a  prophylactic  hemostatic  in  amputations.  The  con- 
strictor must  be  applied  at  a  safe  distance  from  the  proposed  line  of 
section  through  the  soft  parts,  as  otherwise  the  constrictor  may 
slip  after  completing  the  section  through  the  muscles,  the  cut  ends 
of  which  always  retract  much  further  than  would  be  ordinarily  ex- 
pected. The  part  of  the  limb  to  be  removed  should  be  wrapped  in 
a  compress  saturated  with  an  antiseptic  solution, — preferably  carbol- 
ized  water, — to  guard  against  contamination  of  the  wound  from  this 
source  during  the  operation. 

All  incisions  devised  for  flap  formation  are  intended  to  furnish 
tissue  with  which  to  cover  the  sawn  end  of  the  bone  and  the  ampu- 


FLAP    FORMATION. 


1073 


tation   wound.      The   names    of   man}-  distinguished   surgeons   are 
indehbl}-  connected  with  the  different  methods  of  flap  formation 
To  follow  any  or  all  of  the  different  methods  heretofore  devised 
would  not  meet  the  many  exigencies  with  which  the  surgeon  must 
contend.     There  are  certain  well-established  rules  that  should  -uide 
the  surgeon  m  making  the  incisions  through  the  soft  tissues,  which 
will  enable  him  to  act  intelligently  in  cases  in  which  the  local  con- 
ditions  do   not    admit   of  the   adoption   of  any   of  the   orthodox 
methods,  which  are  only  too  often  adhered  to  too  closely   to  the 
detriment  of  the  patient.      In  performing  an  amputation  the  \urgeon 
must  often  rely  on  his  own  ingenuity  in  planning  the  operation  best 
adapted  for  the  ease.      The  operation  should  he  suited  to  the  case  and 
not  the  case  to  the  operation.      No  inflexible  rules  can  be  followed  in 
reference  to  the  location  and  shape  of  the  incisions  in  making  the 
flaps.     The  surgeon  will  take  the  tissues  from  the  side  of  the^'limb 
presenting     the 
most     favorable 
conditions  for  flap 
formation,  and  the 
incisions     will     be 
made   accordingly. 
Circular      amputa- 
tion,    the      oldest 
method  of  remov- 
ing a  limb,  is  sel- 
dom  performed  at 
the     present    day, 


even  in  its  most 
modern  modifica- 
tions. The  old 
operation  and  all 
recent  modifica- 
tions leave  a  scar 
directly  over  the  bone  in  the  center  of  the  end  of  a  stump,  a  loca- 
tion most  exposed  to  irritation.  The  angular  projections  at  the 
two  corners  of  the  wound,  formed  ijy  the  suturing  of  the  wound, 
arc  not  only  unsightly,  but  likewise  interfere  later  with  the  comfort- 
able wearing  of  an  artificial  support.  Amputation  by  the  transfixion 
method,  so  popular  at  one  time,  has  become  nearly  obsolete,  for 
very  obvious  reasons.  In  the  first  place,  nature  does  not  tolerate 
muscular  tissue  over  the  end  of  the  bone,  and  if  placed  there  by  the 
surgeon,  it  is  removed  in  the  course  of  time  by  atrophy  and  ab- 
.sorption.  In  the  .second  place,  the  large  blood-vessels  are  divided 
obliquely,  and  often  cut  for  .some  distance  longitudinally,  leaving 
their  ends  in  a  most  unfavorable  condition  for  lij^ation. 

The  ideal  method  of  Jlap  formation  consists  in  making  two  cutan- 
eous flaps,  oral  in  shape,  one  longer  than  the  other,  including  the  .super- 
ficial and  deep  fascice.      }\y  making  two  flaps  of  uneciual  length  the 
68 


I'ig-  613.  —  Retraction  of  soft  tissues  and  section  of  the  bone 
with  the  saw  (von  Esmarch). 


I074 


AMPUTATIONS    AND    DISARTICULATIONS. 


line  of  suturing  and  the  subsequent  scar  fall  away  from  the  end  of 
the  bone  to  a  place  where  the  scar  tissue  does  the  least  harm  and 
finds  the  best  protection  against  mechanical  irritation.  I  am  strongly 
impressed  with  the  importance  of  including  in  the  flap  the  deep  con- 
nective tissue, — something  that  is  not  generally  advised, — as  by  doing 
so  an  important  hold  on  the  cut  muscles  is  secured,  a  valuable  ele- 
ment in  preventing  retraction  ;  further,  an  additional  source  of  blood 
supply  to  the  flap  is  preserved.  All  amputation  flaps  sliould  include 
the  deep  connective  tissue,  for  the  reasons  just  advanced.  Flaps  must 
be  made  by  cutting  from  without  imvard,  and  never  from  zvithin  out- 
ward. In  forming  the  flaps,  the  surgeon  must  exercise  his  mechan- 
ical ingenuity  in  making  them  of  the  proper  length  and  shape,  so 
that  when  they  are  sutured  together,  the  wound  surface  will  be  cov- 
ered smoothly  and  evenly  without  tension  or  too  great  redundance 
of  tissue  or  any  considerable  pleating  of  the  skin  if  the  wound  mar- 
gins are,  as  is  usually  the  case,  of  somewhat  unequal  length.  The 
student  must  not  forget  that  his  experience  in   operating  on  the 

cadaver  must  be 
somewhat  modi- 
fied when  he 
comes  to  oper- 
ate on  living  tis- 
sues, as  in  the 
latter  case  the 
elastic  and  mus- 
cular contrac- 
tions that  al- 
ways assert 
themselves  as 
soon  as  the  soft 
tissues  are  di- 
vided render  it  necessary  to  make  the  flaps  of  sufficient  length  to 
allow  for  these  contractions.  The  surgeon  who  has  to  use  the 
tape-measure,  and  who  outlines  the  incisions  on  the  surface  of  the 
skin  by  colored  dots  or  lines,  is  not  in  possession  of  the  necessary 
mechanical  skill  to  practise  surgery  successfully.  When  such  an 
amputation  is  completed,  the  surgeon  will  often  find  himself  at  a 
loss  when  he  comes  to  suture  the  flaps.  It  is  well,  in  performing  a 
first  operation  on  the  living  subject,  to  make  ample  provision  for 
retraction  by  making  the  flaps  long,  as  if  they  prove  to  be  too  long, 
the  mistake  can  be  remedied  quickly  and  with  much  less  detriment 
to  the  patient  than  if  they  had  been  made  the  reverse,  the  latter 
mistake  requiring  an  immediate  reamputation,  with  all  its  immediate 
and  remote  consequences. 

Circular  amputation  has  already  been  referred  to  as  an  oper- 
ation that  does  not  yield  a  desirable  stump  for  the  comfortable  wear- 
ing of  an  artificial  limb.  The  operation,  however,  has  many  warm 
advocates,  and  recommends  itself  to  those  who  favor  the  circular 


Fig.  614. — Bruns'  method  of  flap  formation. 


CIRCULAR    AMPUTATION. 


1075 


method  only  in  amputations  of  the  upper  extremity.  It  is  the  oldest 
method  of  amputation,  as  it  was  fully  described  in  the  oldest  text- 
books treating  on  operative  surgery.  The  method  consists  in  divid- 
ing the  soft  tissues  in  either  one  or  two  steps.  The  one-step  oper- 
ation (Celsus)  is  made  by  cutting  all  the  soft  tissues  down  to  the 
bone  by  a  single  circular  sweep  of  the  knife,  and  sawing  off  the  bone 
on  the  same  level.  In  this  manner  the  first  amputations  were  made. 
It  was  impossible  to  suture  the  wound  over  the  end  of  the  bone, 
and  such  wounds  had  to  heal  by  granulation,  resulting  in  a  conic 
stump,  the  apex  of  the  cone  being  the  bone  covered  by  scar  tissue. 
Such  a  stump  is,  of  course,  absolutely  useless  for  the  wearing  of  a 
modern  artificial  limb.  The  difficulty  in  suturing  of  the  wound  was 
overcome  later  by  the  subperiosteal  removal  of  a  piece  of  bone  half 
the  length  of  the  diameter  of  the  limb  (Esmarch).  This  modification 
of  the  original  method  of  circular  amputation  necessitates  two  sec- 
tions of  the  bone,  something  that  should  always  be  avoided. 

Circular  amputation  in  two  steps,  as  devised  and  recommended 
by  Petit  (17 18),  marked  a  decided  improvement  in  the  technic  of 
the  operation,  and  is  the  method  most  generally  practised  at  the 
present  time.  After  elastic  constriction  has  been  applied,  the  limb 
to  be  amputated  is  firmly  grasped  above  the  line  of  proposed  ampu- 
tation by  the  operator's  left  hand,  and  below  by  the  hand  of  an 
assistant.  With  a  small  amputating  knife  the  skin  and  all  the  tissues 
down  to  the  muscles  are  divided  by  a  circular  cut,  either  by  one 
circular  sweep,  or,  better,  by  two  cuts,  the  first  one  on  the  side  of 
the  limb,  away  from  the  operator,  and  the  second  on  the  side  of  the 
limb  toward  the  operator,  the  latter  incision  being  made  by  reversing 
the  position  of  the  knife  in  the  first  sweep.  For  the  same  reasons 
advanced  heretofore  I  recommend  including  in  the  cuff  the  fascia 
embracing  the  muscles.  A  cuff  is  then  reflected  b\'  raising  the 
margins  of  the  skin  with  fingers  or  forceps,  and  separating  the  cuff 
with  delicate  strokes  of  the  scalpel  directed  toward  the  base  of  the 
stump.  The  length  of  the  eiiff  must  correspond  ivith  one-half  of  the 
diameter  of  the  limb.  No  force  or  tearing  is  permissible  in  forming 
the  flap,  as  it  is  advi.sablc  to  di.sturb  the  circulation  as  little  as  pos- 
sible, an  object  best  accomplished  by  making  .short  and  clean  cuts 
directed  perpendicularly  toward  the  base  of  the  circular  flap.  The 
cut  througJi  the  muscles  should  he  made  obliquely  from  bcUnv  upward, 
and  to7uard  the  base,  and  not  straight,  as  is  usually  advised.  After 
the  limb  has  been  .severed,  the  muscular  part  of  the  wound  must 
represent  a  shallow  cup  with  the  end  of  the  bone  as  its  central  point. 
Muscle  retraction  is  most  marked  the  greater  the  distance  from  the 
bone,  as  the  muscles  near  the  bone  retain  many  of  their  attachments. 
By  making  the  incision  obliquely  and  not  straight  this  d/f/erence  is 
more  than  balanced,  an  object  of  much  importance  in  closing  the 
wound  by  suturing.  The  second  incision  should  always  be  made  m 
preference  with  a  strong  scalpel,  with  which  the  obliquity  of  the 
inci.sion  can  be  graded  to  the  rcfiuisite  degree  indicated  by  the  num- 


1076  AMPUTATIONS    AND    DISARTICULATIONS. 

ber,  strength,  and  extent  of  mobility  of  the  muscles  that  must  be 
severed.     The  amputation  is  completed  by  making  the 

Bone  Section. — The  sawn  surface  of  the  bone  must  be  cov- 
ered by  the  normal  envelop  of  the  bone — the  periosteum.  The 
interpositio7t  of  periosteum  between  the  bone  and  tJie  overlying  flap 
is  an  important  technical  part  of  the  operation  and  shoidd  never 
be  neglected.  Osteophytes,  or  any  other  undesirable  consequence, 
need  not  be  feared  if  sufficient  periosteum  is  preserved  to  cover 
and  protect  the  sawn  surface  of  the  bone.  If  the  periosteum 
and  bone  are  normal  at  the  seat  of  amputation,  the  membrane 
is  delicate  and  firmly  attached  to  the  underlying  bone  surface, 
and  should  remain  attached  to  the  neighboring  soft  tissues.  Ac- 
cording to  the  size  and  shape  of  the  bone,  the  periosteal  cover  is 
made  in  the  form  either  of  a  flap  or  of  a  cuff.  A  long  anterior  flap 
is  preferable  for  the  tibia,  while  a  cuff  or  circular  flap  will  answer  an 
excellent  purpose  in  covering  the  sawn  surface  of  all  the  small  and 
round  bones.  The  periosteal  flap  or  cuff  is  made  by  cutting  sepa- 
rately through  the  periosteum  on  a  level  with  the  deep  incision  next 
the  bone,  and,  with  an  elevator,  lifting  up  the  periosteum  in  the 
shape  of  a  flap  or  cuff,  and  detaching  it  far  enough  so  that,  after 
dividing  the  bone,  the  periosteal  flap  or  cuff  will  fall  over  the  end  of 
the  bone  ;  in  the  case  of  large  bones  it  is  fastened  by  one  or  two 
buried  catgut  sutures.  The  bone  is  divided  transversely  with  a 
fine-toothed  amputation  saw. 

It  is  during  this  stage  of  the  operation  that  the  assistant  who  is 
holding  the  limb  must  exercise  special  care.  The  limb  must  be  held 
in  such  a  way  that,  when  the  saw  has  weakened  the  bone  sufficiently 
so  that  it  will  bend,  the  blade  of  the  saw  is  not  caught  and  locked 
between  the  surfaces  encroaching  upon  it ;  on  the  other  hand,  frac- 
ture of  the  unsawn  portion  must  be  prevented  by  not  bending  the 
bone  in  the  opposite  direction.  As  a  rule,  the  assistant's  hands,  if 
they  can  be  relied  upon,  are  the  best  retractors  with  which  to  pro- 
tect the  soft  tissues  against  injury  by  the  saw.  If  the  assistant  is 
not  trustworthy,  retractors  made  of  aseptic  gauze  are  employed  and 
placed  in  charge  of  the  assistant.  The  bone  forceps  come  in  use 
only  when  a  spiculum  of  bone,  the  result  of  fracture,  has  to  be 
removed  ;  it  is  useless  and  even  harmful  to  round  off  the  end  of  the 
bone  with  the  forceps,  as  this  is  done  later  with  greater  nicety  under 
the  periosteal  flap  by  resorption  of  the  sharp  margins.  By  inter- 
posing a  periosteal  covering  between  the  end  of  the  bone  and  the 
overlying  flap  the  former  does  not  become  attached  to  the  latter,  as 
is  usually  the  case  if  this  precaution  is  neglected.  Free  mobility  of 
the  flap  over  the  end  of  the  bone  is  one  of  the  essential  conditions  of 
an  ideal  stump.  The  periosteal  flap,  however,  accomplishes  more 
than  this.  The  medullary  tissue  is  a  structure  exceedingly  sensitive 
to  infection,  and  needs  all  the  protection  we  can  furnish  for  the  pre- 
vention of  traumatic  osteomyehtis.  The  periosteum  is  the  normal 
envelop  of  the  bone,  and  on  this  account  is  best  adapted  as  a  pro- 


LIGATION    OF    BLOOD-VESSELS.  lO// 

tecting  cover  for  the  open  medullary  canal.  By  clo.sing  the  med- 
ullary canal  with  a  periosteal  flap  and  suturing  the  same  in  place 
we  furnish  the  medullary  tissue  with  a  mechanical  protection  in  case 
the  wound  should  become  infected.  After  the  periosteal  flap  has 
been  sutured  in  place,  the  surgeon  attends  to  the 

Ligation  of  Blood = vessels. — Before  the  elastic  constrictor  is 
removed  all  the  principal  blood-vessels  in  the  wound  are  ligatcd. 
Very  coarse  catgut  should  never  be  used.  Medium-sized  catgut 
can  be  relied  upon  in  tying  any  of  the  large  blood-vessels,  and  fine 
catgut  is  used  for  the  small  muscular  branches.  As  the  blood-ves- 
sels, owing  to  their  contractility,  retract  from  the  surface  of  the 
wound,  their  anatomic  location  in  the  cross-section  must  be  familiar 
to  the  surgeon.  The  intermuscular  septa  are  not  only  valuable 
guides  to  the  large  vessels,  but  also  to  the  small  muscular  branches. 
Arteries  the  size  of  the  brachial  and  popliteal  should  be  isolated 
sufficiently  to  secure  room  for  two  ligatures  one-quarter  or  one-third 
of  an  inch  apart,  the  proximal  ligature  including  the  accompanying 
vein,  in  the  manner  described  in  the  section  on  Ligation  of  Blood- 
vessels. Small  vessels  can  be  secured  more  quickly  and  tied  more 
certainly  by  substituting  the  tenaculum  for  the  hemostatic  forceps. 
Before  the  elastic  constrictor  is  removed  the  principal  nerve-trunks, 
if  the  amputation  has  been  made  above  the  wrist-  or  the  ankle- 
joint,  are  searched  for,  drawn  forward  an  inch  or  two,  and  cut  off 
squarely  with  either  the  knife  or  the  sharp  scissors.  The  intermus- 
cular spaces  will  aid  in  searching  for  nerve-ends  retracted  from  the 
surface  of  the  wound.  The  surgeon  must  satisfy  hiin.self,  immedi- 
ately after  the  amputation  is  completed,  that  he  has  made  the  flaps 
properly,  as  any  defects  in  flap  formation  must  be  remedied  before 
any  of  the  blood-\'es.scls  are  tied.  Before  the  elastic  constrictor  is 
removed  the  stump  is  elevated,  the  surface  cov^ered  with  a  compress 
of  gauze  wrung  out  of  a  hot  normal  .salt  solution,  and  the  flaps 
brought  over  the  compress,  when  firm  compression  is  made  with 
both  hands.  It  is  a  mistake  to  remove  the  elastic  constrictor  slowly 
with  the  idea  that  it  tvill  ciiminisJi  the  bleeding,  as  the  result  is  con- 
traiy  to  the  expectations.  The  elastic  constrictor  should  be  removed 
as  snddejily  as  it  ivas  applied.  Manual  compression  is  maintained 
for  a  few  minutes,  until  the  fir.st  arterial  waves  have  passed  by.  The 
escape  of  any  considerable  f|uantity  of  blood  through  the  compress 
would  indicate  that  a  vessel  of  large  size  had  been  overlooked,  in 
which  event  the  compress  is  removed  quickly  and  the  spurting 
point  caught  with  hemo.static  forceps.  If  this  is  not  the  case,  the 
compress  is  removed  inch  by  inch,  and  any  bleeding  point  of  the 
exposed  surface  is  treated  in  the  same  manner  as  described,  until 
the  compress  is  removed,  when  the  ligature  takes  the  place  of  the 
forceps.  Careful  hcmostasis  can  not  be  insisted  upon  too  strongly 
as  the  mo.st  important  preliniinary  .step  to  suturing  of  the  wound. 
Troublesome  surface  oozing  is  arre.sted  by  douching  with  hot  .saline 


1 078 


AMPUTATIONS    AND    DISARTICULATIONS. 


solutions  and  surface  compression.    After  the  wound  has  been  made 
perfectly  dry,  the  next  step  of  the  operation  consists  in 

Suturing  of  the  Wound. — As  the  periosteal  flap  is  fastened  in 
place  before  the  elastic  constrictor  is  removed,  the  first  row  of  sutures 
is  inserted.  Suturing  of  the  cut  muscles  with  heavy  catgut  consti- 
tutes a  very  important  part  of  the  wound  treatment.  The  second 
row  of  buried  sutures  includes  the  ends  of  the  prhtcipal  imiscles,  and 
has  for  its  objects  diminution  of  the  wound  surface  and  the  securing  of 
a  temporary  anchorage  for  the  cut  muscle.  The  diminution  in  the  size 
of  the  wound  by  the  muscle  suturifig  decreases  the  amount  of  primary 
wound  secretion,  short e?is  the  time  of  healing,  and  improves  the  func- 
tional result.  Moreover,  the  temporaiy  attachme?tt  of  the  muscles 
secured  by  the  sutures  is  one  of  the  very  best  means  of  guarding  against 
undue  retraction  and  of  securing  for  the  imiscles  a  condition  of  rest 
best  calcidated  to  prevent  muscular  twitching,  one  of  the  greatest 
sources  of  discomfort  and  pain  after  amputation. 


Fig.  615. — Suturing  of  amputation  wound  (  von  Esmarch)  :    a,  Periosteal   and  deep 
muscle  sutures  ;  b,  buried  muscle  sutures  ;  c,  skin  sutures. 


For  this  suturing  the  needle  should  be  round,  large,  and  well 
curved,  and  the  sutures  should  embrace  corresponding  extensor  and 
flexor  muscles,  one  or  more  of  which  should  rest  on  the  end  of  the 
bone.  These  sutures  contribute  much  toward  giving  the  stump  the 
proper  cone  shape  immediately  after  the  operation.  The  stump  is 
now  ready  for  drainage  and  suturing  of  the  flaps.  All  wounds  made 
by  ampliations  for  inflammatory  affections  must  be  drained.  All 
large  amputation  wounds  must  be  drained.  Small  amputatio?i  zvounds 
after  the  removal  of  a  part  of  a  limb  for  an  aseptic  condition  can  be 
sutured  throughout  without  making  provision  for  drainage.  Drain- 
^S^  ^f  amputation  stumps  should  be  established  where  drainage  is 
most  effective,  and  in  such  a  manner  as  not  to  inteifere  with  pi'imary 
healing  of  the  operation  wound. 

The  best  method  of  draining  an  amputation  wound  consists  in 
making,  at  the  base  of  the  flap,  at  the  most  dependent  portion  of 
the  wound,  a  buttonhole  large  enough  to  insert  a  tubular  drain  of 


DRESSING    OF    THE    STUMP. 


1079 


requisite  size,  which  occupies  the  space  between  the  flap  and  the 
sutured  muscles,  and  should  not  extend  beyond  the  end  of  the  bone. 
The  drain  must  be  well  fenestrated  and  secured  with  a  large  safety- 
pin.  Kocher  secures  the  drain  by  tying  to  its  projecting  part  a  long 
and  strong  silk  thread,  which  is  brought  out  through  the  dressino-. 
When  the  drain  is  to  be  removed  it  can  be  done  without  removing 
the  dressing  by  making  traction  on  the  thread.  The  flaps  must  be 
sutured  as  carefully  as  xvounds  Jiiade  for  plastic  purposes.  Glover's 
needles,  silkworm-gut,  and  horsehair  are  used  for  sewing  the  exter- 
nal wound.  The  wound  margins  must  be  carefully  distributed, 
which  is  most  efTectuall}-  done  by  first  fastening  together  the  center 
of  the  flaps  by  a  central  suture,  and  then  subdividing  each  half  by 
two  lateral  sutures.  Silkworm-gut  of  medium  size  is  the  best  mate- 
rial for  the  deep  interrupted  sutures,  which  must  include  the  entire 
thickness  of  the  flaps.  Usually  two  or  three  sutures  to  the  inch 
will  bring  the  deep  tissues  of  the  flap  in  accurate  apposition.  The 
sutures  must  be  tied  only  with  sufficient  firmness  to  bring  the  mar- 
gins of  the  flap  in  contact,  carefully  avoiding  harmful  linear  com- 
pression. 

Dressing  of  the  Stump. — A  copious  dressing  of  loose  gauze 
and  absorbent  aseptic  cotton,  held  in  place  by  a  gauze  roller,  con- 
stitutes the  best  protection  against  subsequent  infection,  and  at  the 
same  time  is  of  much  service  in  securing  for  the  stump,  what  is  so 
much  needed, — uninterrupted  equable  compression  and  rest.  Before 
the  hygroscopic  dressing  is  applied  the  sutures  are  buried  by 
sprinkling  over  them  the  borosalicylic  powder.  A  separate  ring  of 
cotton  is  placed  around  the  limb  above  the  gauze,  after  which  a 
thick  cushion  of  absorbent  cotton  is  placed  over  the  gauze  and  the 
cotton  ring,  the  whole  being  retained  in  place  by  a  gauze  roller 
carefully  applied.  Every  stump  must  be  iiumobUizcd  as  coustautly 
and  as  carefully  as  a  fractured  limb.  A  well-padded  hollow  splint, 
extending  from  the  end  of  the  stump  along  the  surface  of  the  limbi 
outside  of  the  dressing,  to  a  distance  requisite  to  secure  rest  of  the 
part  of  the  limb  operated  upon,  and  fixed  in  position  by  a  gauze 
roller,  is  the  most  efficient  means  of  securing  muscular  rest,  and 
con.sequcntly  of  preventing  pain  and  of  procuring  for  the  wound  the 
desirable  conditions  for  a  speedy  ideal  primary  healing.  The 
mechanical  support  should  not  be  dispcn.sed  with  until  the  wound 
is  firmly  healed  throughout.  After  the  operation  the  limb  must  be 
placed  at  an  angle  of  at  least  45  degrees  for  from  six  to  twenty-four 
hours,  for  the  purpo.se  of  mininu'zing  the  amount  of  primar}-  wound 
secretion  by  diminishing  the  force  of  the  arterial  circulation  and 
favoring  the  return  of  blood  through  the  veins. 

Cutaneous  Flaps. — The  mo.st  skilful  and  succcs.sful  method  of 
covering  an  amputation  wfjund  is  by  cutaneous  flaps.  As  has  been 
described  above,  the  flaps  should  include  the  aponeurotic  investment 
of  the  muscles  as  an  additional  source  of  blood  supply,  and  as  an 
aid    in   preventing    undue    retraction   of   the  .severed   muscles.      In 


io8o 


AMPUTATIONS    AND    DISARTICULATIONS. 


making  the  flaps  the  surgeon  must  imitate  his  work  in  plastic 
surgery,  paying  due  attention  to  the  blood  supply,  shape,  and  size 
of  the  flaps.  Stephen  Smith  recommended  two  lateral  oval  flaps  of 
equal  size.  The  greatest  objection  to  this  method  of  flap  formation 
is  the  line  of  suturing  and  the  subsequent  location  of  the  scar  directly 
over  the  center  of  the  stump.  The  same  objection  holds  good  if 
similar  anteroposterior  flaps  are  made.  The  one  great  ride  that 
should  govern  the  snrgeojt  in  making  the  incision  is  to  the  effect  that 
the  flaps  should  not  be  of  the  same  length,  in  order  that  the  line  of  sutur- 
ing and  the  subsequent  scar  may  not  be  in  the  center  of  the  end  of  the 
stump.  Another  rule  of  almost  equal  importance  emphasizes  the 
value  of  rounding  off  the  free  margin  of  the  flaps  so  that  they  can 
be  sutured  together  without  wrinkling  the  skin,  which  always  creates 
dead  spaces  and  leaves  the  surface  of  the  stump  uneven.  The 
square  flap  of  Teale  is  open  to  these  objections. 


Fig.  6i6. — Von  Langenbeck's  long  lateral  flap. 

Liston  and  Langenbeck  covered  the  operation  wound  with  one 
long  oval  flap,  which,  from  a  technical  point  of  view,  has  much  to 
recommend  it.  The  method  is  Hkewise  well  adapted  for  amputa- 
tion of  the  fingers,  as  it  yields  a  sightly  and  useful  stump.  A  long 
oval  flap  from  either  the  dorsal  or  the  palmar  side  covers  the  wound 
perfectly,  and  the  Hne  of  suturing  falls  away  from  the  surface  of  the 
end  of  the  stump.  The  tissues  of  the  fingers  are  so  well  supplied 
with  blood  that  there  is  no  danger  of  sloughing  of  the  flap  from  this 
source,  which  is  not  the  case  if  the  amputation  is  made  above  the 
middle  of  the  forearm  or  above  the  ankle-joint,  where  the  circula- 
tion in  the  skin  is  less  vigorous  and  the  danger  of  sloughing  con- 
sequently increased. 

The  method  of  flap  formation  devised  by  von  Bruns,  consisting 
of  a  long  oval  anterior  and  a  short  oval  posterior  flap,  recommends 
itself  as  the  most  advantageous,  certainly  yielding  the  best  imme- 
diate  and  remote   results  (Fig.  614).      This  method  of  amputation 


MUSCULOCUTANEOUS    FLAPS. 


1 08  I 


Fig.  617. — Von  Walther's  lateral   radial  flap  for 
disarticulation  at  the  wrist-joint. 


yields  the  most  serviceable  stumps  for  the  wearing  of  artificial 
limbs,  and  should  therefore  constitute  the  operation  of  choice  in  all 
amputations  of  the  lower  extremity  above  the  ankle-joint.  If  the 
local  conditions  indicate  it,  the  operation  can  be  modified  by  making 
a  long  oval  posterior  and  a  short  oval  antenor  flap,  or  by  making 
oval  lateral  flaps  of  unequal 
length.  The  remaining  steps 
of  the  operation  are  identical 
with  circular  amputation  as 
described. 

Musculocutaneous 
Flaps. — The  formation  of 
musculocutaneous  flaps  by 
transfixion  has  been  men- 
tioned more  for  the  purpose 
of  recalling  a  step  in  the 
evolution  of  the  history  of 
amputation  than  with  any 
intention  of  giving  a  full 
description  of  the  operation. 
Langenbeck  improved  the 
operation  by  making  the 
flap  by  incision  from  with- 
out inward,  instead  of  by  transfixion.  He  invented  and  used  a  small 
amputation  knife  in  place  of  old-fashioned  transfixion  instruments. 
The  musculocutaneous  flap  is  the  one  especially  adapted  for  disar- 
ticulation at  the  shoulder-joint,  when  the  operation  most  frequently 
performed  is  b\-  a  long  oval  flap  that  includes  the  deltoid  muscle. 

AMPUTATIONS  OF  THE  UPPER  EXTREMITY. 
No  such  sharp  distinction,  from  a  descriptive,  anatomic,  and 
practical  standpoint,  is  made  between  amputation  and  exarticulation 
in  this  country  as  on  the  European  Continent.  We  are  in  the  habit 
of  speaking  of  amputation,  rather  than  disarticulation,  at  the  shoul- 
der-joint or  hip-joint.  The  old  text-books  on  operative  surgeiy 
teem  with  the  names  of  surgeons  who  have  devised  new  methods 
of  amputation  and  various  modifications,  and  they  contain  confusing 
accounts  of  the  anatomic  descri[)tions  upon  which  some  of  them  are 
ba.sed.  The  student's  memory  has  been  largely  taxed  by  attempts 
to  master  the  technic  of  the  different  operative  procedures  and  in 
the  endeavor  to  remember  the  indications  for  the  same.  Many  an 
examination  for  the  professional  degree  has  been  made  memorable 
by  questions  n.lating  to  the  details  of  complicated  methods  of  am- 
putation, which  the  candidate  never  expected  to  perform,  and  con- 
cerning which  the  e.xaminer's  knowledge  was  limited  to  what  he 
learned  by  glancing  over  the  pages  of  a  superannuated  text-book  on 
surgery.  We  have  insisted  before  that  the  most  successful  surgeon 
is  the  one  who  is  familiar  with  anatomy  and  surgical  pathology,  and 


io82 


AMPUTATIONS    AND    DISARTICULATIONS. 


who  is  endowed  with  the  requisite  amount  of  common  sense  and 
mechanical  skill  to  plan  and  execute  methods  and  modifications  of 
amputations  appropriate  for  each  individual  case.  Incalculable  harm 
has  been  done  by  blindly  following  the  footsteps  of  others,  and  this 
is  more  especially  true  of  amputations.  The  surgeon  must  be 
familiar  with  the  principles  that  underlie  the  manual  part  of  his 
work,  the  details  and  special  applications  of  which  principles  require 
originality  of  thought  and  action. 

In  the  operative  removal  of  any  part  of  the  upper  extremity  the 


Fig.  6i8. — Disarticulation  of  the  fingers  :  disarticulation  of  the  middle  finger  at  the 
interphalangeal  joint ;  opening  of  the  joint  on  its  dorsal  aspect.  Formation  of  a  palmar 
flap  by  incision  from  within  outward.  Upon  the  thumb  :  line  of  incision  for  removal  of 
the  thumb  at  the  carpometacarpal  joint  by  means  of  an  oval  incision.  Upon  the  index- 
finger  :  flap  incisions  (Zuckerkandl). 


ultimate  object  of  the  operation  must  have  in  view  a  maximum  func- 
tional result.  Conservatism  to  its  extreme  limits  is  the  rule  that 
must  guide  the  surgeon  in  performing  mutilating  operations  on  the 
fingers  and  hands.  The  prehensile  power  must  be  preserved  as  far 
as  possible  in  the  treatment  of  injuries  and  destructive  inflammatory 
affections  of  the  fingers  and  hands.  The  hand  is  the  part  of  the 
body   where   atypical    operations   are   most   frequently   performed. 


AMPUTATIONS    OF    THE    UPPER    EXTREMITY. 


1083 


Every  finger  and  every  joint  of  a  finger  are  necessary  for  the  full 
grasping  power  of  the  hand,  but  the  most  important  part  of  the 
prehensile  apparatus  is  the  thumb;  for  this  reason  the  surgeon  is 
always  anxious  to  save  every  inch  and  every 
fraction  of  an  inch  of  this  tiie  most  useful  mem- 
ber of  the  hand. 

In  the  disarticulation  or  amputation  of  a 
finger  below  the  metacarpophalangeal  joint  the 
operation  of  choice  is  to  cover  the  wound  with  a 
long  palmar  flap,  but  if  the  conditions  are  such 
that  more  of  the  finger  can  be  saved  by  making 
a  dorsal  or  a  lateral  flap,  the  surgeon  should 
never  hesitate  to  pursue  the  more  conservative 
course.  The  skin  on  the  palmar  side  of  the 
fingers  is  best  adapted  as  a  covering  for  the  am- 
putation wound,  and,  as  it  is  freely  supplied  with 
blood-vessels  and  possesses  a  maximum  intrinsic 
recuperative  power,  there  is  very  little,  if  any,  risk 
of  gangrene  in  covering  the  wound  with  one 
long  oval  flap.  The  flap  should  always  be  made 
by  cutting  from  without  inward,  never  by  transfixion.  If  anything 
can  be  gained  in  preventing  harmful  shortening  of  the  finger  by 
making  a  dorsal  or  lateral  flap,  the  surgeon  adapts  himself  to  exist- 
ing circumstances  and  pursues  the  most  conservative  course.  A 
very  important  rule  to  follow  in  amputating  a  finger  below  its  ba.se, 
and  one  that  is  too  often  ignored,  is  to  suture  the  extensor  to  the 
flexor  tendon  over  the  articular  end  or  sawn  surface  of  the  bone. 


Fig.  619. — Stump 
after  exaiticulation  of 
the  last  four  metacar- 
pal bones  (von  Es- 
march). 


Fig.  620. — Disarticulation  of  the  tliumi)  \>y  radial  flaj)  (after  von  Walllicr). 


Tendon  suture  under  such  circumstances  becomes  a  necessity,  for 
the  purposes  of  preventing  imdue  retraction  of  the  flap  and  of  fur- 
nishing the  cut  ends  of  the  tendons  with  a  permanent  point  of  anchor- 
age. Immobilization  of  the  stump  is  essential  in  procuring  the 
conditions  necessary  for  an  ideal  healing  of  the  woiuid.  The  fixa- 
tion dressing  should  include  the  hand,  and  must  remain  imtil  the 
wound  is  firmly  liealed. 


1084 


AMPUTATIONS    AND    DISARTICULATIONS, 


In  injuries  and  diseases  of  the  hand,  plastic  operations  often  be- 
come necessary  for  the  restoration  of  the  soft  tissue  and  preservation 
of  the  bony  framework.  Atypical  operations,  in  attempts  to  pre- 
serve as  much  as  possible  of  the  prehensile  power  of  the  hand,  are 
in  vogue  here  more  than  elsewhere.  The  loss  of  a  metacarpal  bone 
has  been  successfully  replaced  by  an  autoplastic  operation,  consist- 
ing in  transplanting  one  half  of  the  adjacent  bone.  In  extensive 
injuries  of  the  hand  the  prehensile  power  is  preserved  to  a  wonder- 


Fig.  621. — Transverse  incision  through  the  middle  third  of  the  left  forearm  (after 
Zuckerkandl)  :  r.,  Radius;  u.,  uhia ;  F.s.,  flexor  digitorum  sublimis  ;  P.p.,  flexor  digi- 
torum  profundus;  U.i.,  ilexor  carpi  ulnaris  ;  R.i.,  flexor  carpi  radialis  ;  P. I.,  palmaris 
longus  ;  S.L,  supinator  longus  ;  Ext.,  group  of  extensor  muscles  ;  U.,  ulnar  artery  in  a 
common  sheath  with  the  corresponding  veins  and  ulnar  nerve  ;  R.,  radial  artery  with  the 
corresponding  veins  and  nerve  ;  M.,  median  nerve  ;  J.,  interosseous  artery. 

ful  extent  by  preserving  the  thumb  and  little  finger,  with  the  corre- 
sponding metacarpal  bones.  In  disarticulations  at  the  metacarpo- 
phalangeal joints  the  head  of  the  metacarpal  bone  should  always 
be  preserved  in  cases  in  which  a  good  functional  result  is  of  greater 
consequence  than  the  cosmetic  effect.  Two  lateral  oval  flaps  of 
equal  length  furnish  the  best  covering  for  the  head  of  the  meta- 
carpal bone.  In  disarticulation  of  the  little  and  index-fingers  and 
thumb  the  flap  is  taken,  in  preference,  from  the  palmar  surface. 
Conservatism  to  the  maximum  limits  is  indicated  more  especially  in 


AMPUTATIONS    OF    THE    UPPER    EXTREMITY.  IO85 

operations  about  the  base  of  the  thumb,  as  the  metacarpal  bone  of 
this  finger  constitutes  an  important  part  of  the  grasping  power  of  the 
hand. 

In  amputations  at  and  above  the  wrist-joint  conservatism,  as  far 
as  the  length  of  the  stump  is  concerned,  is  of  minor  importance, 
although  the  rule  holds  good  here  to  make  the  operation  as  far 
away  from  the  trunk  as  is  compatible  with  the  indications  necessi- 
tating the  operation. 

In  amputations  of  the  arm  and  forearm  and  disarticulation  at 
the  elbow-  and  wrist-joints,  the  best  immediate  and  remote  results 
are  obtained  by  making  oval  anteroposterior  flaps  of  unequal  length. 
It  is  immaterial  on  which  side  the  long  flap  is  made.  In  amputations 
of  the  forearm  it  is  often  convenient  and  advisable  to  cover  the 
wound  by  one  oval  lateral  flap  from  either  the  radial  or  the  ulnar 
side,  as  indicated  by  the  location  of  the  injury  or  the  disease  that 
necessitated  the  operation.  For  disarticulation  of  the  wrist-joint 
von  Walther  recommended  such  a  flap  to  be  taken  from  the  radial 
side  (Fig.  617).  Muscle  or  tendon  suture  over  the  end  of  the  bones 
of  the  forearm  adds  materially  to  the  desirable  form  of  the  stump 


Fig.  622. — Disarticulation  at  tlie  elbow-joint;   flap  incision  (Zuckerkandi). 

and  its  u.sefulne.ss.  During  the  suturing  and  dressing  of  the  woimd 
the  stump  must  be  held  in  a  flexed,  elevated  position,  half-way 
between  pronation  and  supination.  In  this  position  it  is  immobilized 
either  by  applying  a  few  turns  of  the  plaster-of- Paris  bandage  over 
the  dressing  or  by  the  use  of  a  well-padded  hollow  splint.  In 
high  amputations  of  the  forearm  it  must  not  be  forgotten  that  even 
a  short  stumj)  is  of  great  service  to  the  patient,  and  that  on  this 
account,  if  for  no  other,  a  very  high  amputation  is  preferable  to 
exarticulation  at  the  elbow-joint. 

Disarticulation  at  the  dbow-joint  by  a  long  anterior  .semilunar 
and  a  short  posterior  semilunar  flap  recommends  itself  as  the  best 
technical  procedure  when  such  an  operation  is  in  consonance  with 
the  conditions  it  is  intended  to  remove.  An  oval  incision  an  inch 
and  a  half  below  the  condyles  outlines  the  long  anterior  flap,  after 
which  the  forearm  is  forcibly  flexed  and  rotated  in  such  a  manner 
that  the  po.sterif)r  surface  of  the  joint  is  directed  forward.  A 
slightly  oval  incision  from  our.  cr)n(l>le  to  the  other  divides  the 
skin,  fascia,  tricei)s  tendon,  and  lateral  ligaments  ;  and  a  .second 
inci.sion  severs  the  remaining  structures  on  the  anterior  siuface  of 


io86 


AMPUTATIONS    AND    DISARTICULATIONS. 


w:.efl 


the  joint.  After  the  hemostasis  and  nerve  exsection  have  been 
completed,  the  tendon  of  the  biceps  is  united  with  the  tendon  of 
the  triceps  with  one  or  two  sutures  of  strong  catgut.  The  stump, 
properly  immobilized,  should  be  bandaged  over  a  cushion  of  ab- 
sorbent cotton  to  the  side  of  the  chest,  for  the  purpose  of  securing 
the  desired  rest. 

Amputation  of  the  arm  between  the  elbow-  and  shoulder-joints 
is  one  of  the  easiest  of  all  major  operations.  Semilunar  flaps  of 
unequal  length  are  usually  made,  although  a  circular  amputation 
in  two  steps,  as  has  been  described,  has  a  practical  application,  more 

especially  in  cases  in 
which  it  is  desirable 
to  complete  the  op- 
eration in  a  few  min- 
utes. Neuromata  are 
very  prone  to  develop 
in  stumps  after  ampu- 
tations of  the  arm  and 
upper  part  of  the  fore- 
arm, and  for  this  rea- 
son the  surgeon  must 
exercise  the  neces- 
sary care  for  their 
prevention  by  pri- 
mary nerve  excision 
and  by  securing  heal- 
ing of  the  wound  by 
primary  intention. 

Disarticulation  at 
the  shoulder-joint 
presents  no  unusual 
technical  difficulties 
aside  from  diverting 
hemorrhage  during 
the  operation.  It  is 
in  this  locality  that 
the  flap  formation 
should  include  the 
muscles,  provided  this  can  be  done  without  incurring  any  risk 
of  incomplete  removal  of  diseased  tissue.  Prophylactic  hemostasis 
is  effected  either  by  elastic  constriction  or  by  preliminary  ligation 
of  the  axillary  artery.  Elastic  constriction  above  the  joint  is  made 
by  passing  a  mattress  or  stout  steel  needle  from  before  backward, 
between  the  neck  of  the  scapula  and  the  axillary  vessels,  making 
the  constriction  between  the  needle  and  the  chest.  The  constric- 
tion is  made  with  an  Esmarch  constrictor,  rubber  tubing,  or,  if  these 
contrivances  are  not  at  hand,  with  an  elastic  suspender  or  a  Spanish 
windlass.      The  needle  must  transfix  the  tissues  at  a  point  sufficiently 


Fig.  623. — Transverse  section  through  the  middle 
third  of  the  right  arm  (von  Esmarch)  :  v.c.  Cephalic 
vein;  «.r.,  musculospiral  nerve  ;  «./.,  profunda  artery  ; 
n.c.e.p.,  external  cutaneous  nerve  ;  a.b.,  brachial  arteiy  ; 
«.?«.,  median  nerve  ;  n.c.i.m.,  greater  internal  cutane- 
ous nerve  ;  v.b.,  basilic  vein  ;  nai.,  ulnar  nerve. 


AMPUTATION    OF    THE    ARM. 


1087 


far  above  the  joint  to  hold  the  constrictor  safely  in  place  after  the  disar- 
ticulation has  been  made.  As  an  additional  safeguard  against  the  slip- 
ping of  the  constrictor  it  is  advisable  to  transfix  the  skin  zvitli  a  smaller 
needle  over  the  shotdder,  two  and  a  half  to  three  inches  from  the  mar- 
gin of  the  acromion  process.  Elastic  constriction  applied  in  this 
manner  temporarily  cuts  off  all  blood  supply  below  the  constricting 
line,  and  is  a  favorite  method  of  controlling  hemorrhage  in  disar- 
ticulation at  the  shoulder-joint. 

The  same  object  is  attained,  although  to  a  less  nearly  perfect 
degree,  by  preliminary  ligation  of  the  axillaiy  arter)-.  After  making 
the  long  semilunar  flap,  including  the  entire  deltoid  muscle,  and 
turning  it  upward,  the  shoulder-joint  is  fully  exposed,  the  capsular 
ligament  cut  sufficiently  to  dislocate  the  head  of  the  humerus,  when 
the  free   part  of  the   humerus  is  displaced   laterally  sufficiently  to 


Fig.  624. — Flap  incisions  for  amputation  and  disarticulation  of  the  arm  (Zuckerkandl). 


expose  the  axillary  vessels  for  ligation.  The  axillary  artery  is  tied 
above  the  proposed  line  of  amputation,  and  a  .second  ligature, 
about  a  third  of  an  inch  lower  down,  includes,  besides  the  artery, 
the  corresponding  vein.  After  applying  the  hemostatic  forceps  to 
the  artery  below  the  last  ligature,  the  vessel  is  cut  between  and  the 
incision  made  from  this  point  from  within  outward,  in  forming  the 
inner  short  .semilunar  flap.  liy  proceeding  in  this  manner  no  blood 
is  lo.st  from  the  principal  vessels,  and  in  making  the  external  flap 
the  spurting  points  are  caught  with  hemostatic  forceps,  which  are 
relied  upon  during  the  ojjcration  to  control  the  hemorrhage  from 
this  source. 

Kla-stic  constriction  merits  the  preference  in  cases  in  which  the 
less  of  even  a  small  quantity  of  blood  might  prove  disastrous  to  the 
patient,  while   preliminary   ligation   is   the   method   of  choice  in  all 


I088  AMPUTATIONS    AND    DISARTICULATIONS. 

other  cases,  more  especially  in  disarticulation  for  malignant  disease 
and  infective  lesions  that  have  encroached  closely  upon  the  shoul- 
der-joint. The  deltoid  musculocutaneous  flap  fills  in,  cushion  like, 
the  large  lateral  defect  created  by  the  disarticulation,  preserving  the 
rotundity  of  the  shoulder,  while  a  cutaneous  flap  leaves  the  acro- 
mion process  as  an  unsightly  and  often  inconvenient  prominence. 

The  amputation  wound  is  drained  through  a  buttonhole  made  in 
the  center  and  at  the  base  of  the  short  inner  flap,  leaving  the  wound 
free  to  be  sutured  throughout.  A  copious  dressing,  held  in  place 
by  broad  strips  of  adhesive  plaster  and  gauze  bandage,  is  relied 
upon  in  protecting  the  wound  against  infection  and  in  procuring  and 
maintaining  rest  for  the  wound.  The  patient  should  be  placed  in 
the  recumbent  position,  with  the  chest  slightly  elevated,  and  con- 
tinued so  for  at  least  a  week.  In  cases  requiring  haste  in  complet- 
ing the  disarticulation  the  arm  is  amputated  by  the  circular  method, 
below  the  shoulder-joint,  in  the  usual  manner.  A  vertical  incision 
is  then  made  down  to  the  bone,  through  the  center  of  the  deltoid 
muscle,  from  the  end  of  the  stump  to  the  acromion  process,  the 
bone  being  enucleated  through  this  incision  with  knife  and  periosteal 
elevator.  Drainage  is  established  through  a  separate  opening,  and, 
after  closing  the  vertical  incision,  the  circular  incision  is  sutured  in 
an  anteroposterior  direction. 

Exarticulation  of  the  entire  upper  extremity,  including  the 
scapula  and  clavicle,  is  a  very  formidable  procedure  and  attended 
so  far  by  a  frightful  mortality  ;  for  these  reasons,  therefore,  it  should 
never  be  lightly  undertaken  and  never  without  adequate  reliable 
assistance.  The  operation  is  performed  for  the  removal  of  malig- 
nant tumors  of  the  arm  beyond  the  reach  of  disarticulation  at  the 
shoulder-joint,  usually  for  sarcoma  of  the  humerus  with  extension 
of  the  disease  to  the  shoulder-joint.  Occasionally  it  becomes  nec- 
essary for  malignant  disease  of  the  scapula  with  implication  of  the 
soft  tissues  in  a  direction  that,  for  its  removal,  demands  the  sacrifice 
of  the  whole  upper  extremity.  The  only  prophylactic  hemostatic 
precaution  in  the  removal  of  the  whole  shoulder-girdle  is  the  pre- 
liminary ligation  of  the  first  part  of  the  axillary  artery.  I  have 
always  performed  this  step  of  the  operation  through  the  amputation 
wound  after  making  the  anterior  branch  of  the  oval  incision.  It  is 
not  always  necessary  to  remove  the  entire  clavicle,  and,  if  possible, 
it  should  invariably  be  avoided. 

The  incision  is  commenced  over  the  clavicle,  at  a  point  where  it 
is  the  intention  to  disarticulate  or  divide  the  bone,  and  is  carried  in 
front  over  the  bone,  until  the  tendinous  expansion  of  the  pectorahs 
major  muscle  is  reached  ;  from  here  it  is  continued  downward  to  the 
anterior  axillary  border.  After  section  of  the  pectoral  muscles,  the 
upper  part  of  the  axillary  artery  can  easily  be  reached  and  tied. 
The  posterior  branch  of  the  incision  is  then  made,  starting  from  the 
straight  incision  and  carrying  it  over  the  acromion  process  in  the 
directionof  the  posterior  axillary  border,  then  in  a  forward  direction 


AMPUTATIONS    OF    THE    LOWER    EXTREMITY. 


1089 


Fig.  625. — Removal 
of  the  whole  upper  ex- 
tremity (Berger). 


until  it  meets  the  anterior  branch,  in  the  center  of  and  near  the  base 
of  the  axillary  space.  The  cutaneous  borders  are  reflected  back- 
ward until  the  parts  to  be  removed  are  freely  exposed,  when  the 
whole  clavicle  or  the  part  to  be  excised  is  lifted  carefully  from  its 
bed  by  the  cautious  use  of  the  knife  and  the  free  resort  to  the  peri- 
osteal ele\ator.  The  scapula  is  liberated  by 
rapid  strokes  of  a  strong  scalpel,  and  the 
operation  finished  with  all  possible  speed,  for 
in  spite  of  the  diligent  and  expert  use  of 
hemostatic  forceps,  hemorrhage  is  quite  free 
and  sometimes  alarming  during  this  step  of 
the  operation.  Special  care  is  required  dur- 
ing the  last  part  of  the  exarticulation  to  divide 
the  vessels  and  tissues  around  them  at  a  safe 
distance  hdcnv  the  ligature.  Two  drains 
should  be  employed  in  draining  the  enor- 
mous wound,  each  at  least  of  the  thickness 
of  the  middle  finger.  One  of  the  drains  is 
brought  out  through  a  buttonhole  in  front  of 
the  axillary  space  at  the  lowest  part  of  the 
wound  ;  the  other,  through  a  similar  opening 
posteriorly  on  the  same  lev^el,  draining  the 
scapular  side  of  the  wound.  The  dressing  and  fixation  are  the  same 
as  after  disarticulation  at  the  shoulder-joint. 

AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 

In  man  the  lower  extremities  are  intended  principally  for  loco- 
motion, and  in  performing  amputations  the  surgeon's  aim  should 
be  to  interfere  as  little  as  pos.sible  with  this  important  function.  In 
all  amj)utations  between  the  junction  of  the  middle  with  the  lower 
third  of  the  leg  and  through  the  lower  part  (jf  the  upper  third  of 
the  thigh,  the  operation  is  planned  and  executed  with  special  refer- 
ence to  securing  a  painless,  useful  stump  for  the  wearing  of  an 
artificial  limb.  To  meet  this  indication  in  a  .satisfactory  manner 
without  coming  into  conflict  with  the  main  purpo.se  of  the  amputa- 
tion requires  frequently  a  very  keen  judgment  and  no  small  degree 
of  originality  in  devising  the  method  of  operating  appropriate  for 
each  individual  case.  No  inflexible  rules  can  be  laid  down  for  the 
guidance  f)f  the  surgeon.  It  is  in  difficult  cases  requiring  excep- 
tional methods  of  operating  that  the  surgeon  can  show  liis  skill 
and  moral  c(;urage  to  the  best  advantage,  based  on  a  comprehen- 
sive knowledge  of  the  pathologic  conditions  with  which  he  has  to 
deal,  and  his  ingenuity  in  devising,  often  on  the  spur  of  the 
moment,  new  operative  procedures  to  meet  the  exigencies  of  the 
case. 

Amputation  of  Toes. —In  injuries  and  diseases  of  the  toes 
requiring  amputation  the  rule  to  .save  as  much  ti.ssue  as  po.ssible, 
so  forcibly  laid  down  in  amputations  of  the  fingers,  does  not  apply. 
69 


1090  AMPUTATIONS    AND    DISARTICULATIONS. 

The  functional  results  are  much  better  after  the  removal  of  a  whole 
than  of  a  part  of  a  toe.  Resection  as  a  substitute  for  amputation 
in  inflammatory  affections  of  the  joints  of  the  toes,  with  the  excep- 
tion of  the  metatarsophalangeal  joint  of  the  big  toe,  can  not  be 
advocated,  as  was  done  in  similar  affections  of  the  fingers.  The 
complete  removal  of  any  one  of  the  toes,  with  the  exception  of  the 
first  one,  does  not  impair  the  usefulness  of  the  foot,  and  there  is, 
therefore,  no  excuse  for  conservatism.  Cases  of  dry  gangrene, 
however,  are  exceptions  to  this  statement,  the  removal  of  the  gan- 
grenous part  after  the  line  of  demarcation  has  been  well  estab- 
lished being  the  best  procedure,  as  a  typical  operation  by  any 
other  course,  under  such  circumstances,  is  not  infrequently  followed 
by  sloughing  of  the  margins  of  the  flaps  and  extension  of  the  gan- 
grene. A  stump  after  amputation  of  any  of  the  toes  adds  nothing 
to  the  usefulness  of  the  foot  ;  on  the  contrary,  it  is  usually  in  the 
way  in  wearing  a  shoe  and  in  walking,  and  often  becomes  the  seat 
of  troublesome  inflammatory  affections  caused  by  infection  through 
abrasions  produced  by  mechanical  irritation. 

In  injuries  and  destnictive  affections  of  an  isolated  toe  the 
operation  of  cJioice,  ivitJi  the  exceptions  previously  stated,  should 
alzvays  be  disarticidation  at  the  metatarsophalangeal  joint,  followed 
by  resection  of  the  head  of  the  corresponding  metatarsal  bone. 
In  amputations  of  the  first  and  fifth  toes  the  principal  flap 
must  be  taken  from  the  plantar  side,  as,  owing  to  its  structure 
and  prolonged  use  by  supporting  the  weight  of  the  body  in 
standing  and  walking,  it  is  much  better  adapted  for  a  lateral  cov- 
ering of  the  foot  than  is  the  dorsal  side.  In  amputating  any  of 
the  remaining  toes  the  oval  incision  is  commenced  on  the  dorsal 
side,  over  the  center  of  the  metatarsal  bone,  above  its  head,  and  is 
extended  On  each  side  of  the  base  of  the  toe,  joining  in  the  middle 
on  the  plantar  side.  With  a  few  strokes  of  the  knife  the  joint  is 
exposed,  and,  by  a  transverse  cut  on  the  dorsal  side,  the  extensor 
tendon  and  ligaments  are  cut  and  the  disarticulation  completed 
under  extreme  flexion  of  the  toe.  After  cleaning  the  bone  above 
the  head  of  the  metatarsal,  the  bone  section  is  made  by  the  use  of 
small  bone-cutting  forceps.  After  careful  hemostasis  the  heart- 
shaped  wound  is  sutured  throughout  in  its  long  axis,  unless  there 
are  special  reasons  for  establishing  drainage. 

In  amputation  of  the  great  toe  the  metatarsal  bone  above  its 
head  should  be  divided  obliquely  with  a  small  saw,  as  resection  by 
a  transverse  section  of  the  bone  would  leave  a  sharp  prominence  that, 
in  this  locality,  must  be  carefully  avoided,  for  obvious  reasons.  Dis- 
articulation, on  the  other  hand,  without  resection  of  the  head  of  the 
metatarsal  bone  would  leave  an  unsightly  and  troublesome  protuber- 
ance, the  source  of  a  great  deal  of  discomfort  and  distress  in  the 
subsequent  wearing  of  a  shoe.  The  large  sesamoid  bone,  so  con- 
stantly found  in  this  locality,  should  be  removed,  as  its  presence  in 
the  tissues  is  liable  to  become  a  source  of  irritation  when  the  patient 


DISARTICULATION    OF    ALL    THE    TOES. 


1 09  I 


resumes  the  use  of  the  foot.  If  it  becomes  necessary  to  remove  the 
corresponding-  metatarsal  bone,  whole  or  on  a  higher  level  than  is 
necessary  for  resection  of  its  head,  the  dorsal  incision  is  extended 
to  the  requisite  extent. 

Disarticulation  of  all  the  toes  occasionally  becomes  necessary 
for  crushing  injuries  or  gangrene  following  frost-bite.  The  dorsal 
incision  is  made  from  one  side  of  the  foot  to  the  other,  'directly  over 
the  metatarsophalangeal  joints.  These  latter  are  then  opened 
while  the  toes  are  held  in  a  strongly  flexed  position,  and  the  plantar 
flap,  which  is  depended  upon  entirely  as  a  covering  for  the  wound, 
is  made  by  cutting  either  from  without  inward  or  from  the  line  of 
disarticulation  outward.      It  is  preferable  to  make  the  flap  by  cutting 


Fig.   626. — Disarticulation    of    all    the    toes    (von    E.smarch)  :    a.   Plantar    inci.sion  ;  l>, 

dorsal  incision. 


from  without  inward,  as  in  doing  so  the  operator  is  in  a  better  posi- 
tion to  secure  proper  length  and  shape  of  the  flap.  The  plantar 
flap  mu.st  be  made  sufficiently  long  to  permit  of  its  being  sutured 
to  the  margin  of  the  dorsal  inci.sion  without  [)roducing  tension. 
Making  the  flap  too  short  is  not  a  rare  mistake.  In  this  operation 
the  heads  of  all  the  metatarsal  bones  are  j)rcserved.  as  their  exci- 
sion would  .seriously  impair  the  plantar  arch  and.  in  the  same  ratio, 
the  functional  utility  of  the  UuA. 

Amputation  through  the  metatarsus  at  au)-  Icxd  is  made  l)y 
the  same  method  of  (lap  formation  as  in  disarticulation  at  the  meta- 
tarsoi)halangeal  joints — that  is,  by  covering  the  wound  with  an  oval 
plantar  flap.  After  clearing  the  bones  at  the  proposed  line  of  ampu- 
tation, the  section   is  made  with  an  ordinary  amjjutation  saw.      The 


1092 


AMPUTATIONS    AND    DISARTICULATIONS. 


obstinate  oozings  from  the  medullary  canals,  as  well  as  the  size  of 
the  wound,  are  usually  regarded  as  sufficient  reasons  for  establish- 
ing tubular  drainage.  There  is  no  objection  in  such  cases  to 
through  tubular  drainage  from  one  angle  of  the  wound  to  the  other, 
leaving  the  stitch  nearest  the  angle  of  the  wound  untied  until  after 
the  removal  of  the  tubular  drain. 

Lisfranc's  tarsometatarsal  disarticulation  has  become  obsolete. 
This  operation  has  been  the  stumbling-block  of  medical  students 
and  the  dread  of  the  operator  in  the  clinical  amphitheater  since  it 
was  devised  by  the  illustrious  surgeon  whose  name  it  bears.  When 
this  operation  was  originated  it  met  with  well-deserved  favor,  as  the 
suppuration  that  so  constantly  followed  nearly  every  operation  was 
known  to  prove  less  disastrous  in  disarticulations  than  in  amputations 

that  required  bone 
section  and  the  un- 
avoidable exposure 
of  the  medullary 
tissue  to  infection, 
with  all  its  serious 
immediate  and  re- 
mote consequences 
— o  s  t  e  o  m  y  e  1  itis, 
sepsis,  pyemia,  and 
necrosis.  Asepsis 
has  removed  this 
objection,  and  the 
surgeon  is  now  free 
in  the  use  of  the 
saw  in  the  neigh- 
borhood of  Lis- 
franc's joint.  If, 
on  making  the  line  of  section,  any  of  the  articular  ends  are  found  free, 
they  are  removed  ;  if  attached,  they  are  permitted  to  remain.  In  all 
amputations  between  the  ankle-joint  and  the  base  of  the  toes  the 
stump  must  be  immobilized  at  a  right  angle  to  the  leg,  and  the  fix- 
ation dressing,  plaster-of- Paris  bandage,  or  a  well-padded  posterior 
hollow  splint  must  include  the  leg  as  far  as  the  head  of  the  tibia. 

Mediotarsal  Disarticulation. — Mediotarsal  disarticulation,  an 
operation  devised  by  Chopart,  has  recently  been  severely  criticized, 
and  many  surgeons  have  abandoned  it,  claiming  that  the  stump  is 
less  serviceable  to  the  patient  than  an  artificial  limb  after  amputation 
of  the  leg  at  the  point  of  election,  and  that  the  immediate  risk  to  life 
is  not  increased  by  substituting  amputation  of  the  leg  for  Chopart' s 
disarticulation.  My  experience  has  satisfied  me  that  the  functional 
result  following  Chopart's  operation,  when  properly  performed,  is  an 
excellent  one — by  far  superior  to  anything  that  could  be  furnished 
by  the  instrument  maker  after  an  amputation  of  the  leg.  The  diffi- 
culty heretofore  connected  with  the  mediotarsal  amputation  has  been 


Fig.  627. — Amputation  through  metatarsus  (von  Es- 
march)  :  a,  Section  with  saw  ;  b,  appearance  of  wound  after 
amputation. 


MEDIOTARSAL    DISARTICULATION. 


1093 


in  preventing  retraction  of  the  heel.  Subcutaneous  section  of  the 
tendo  AchilHs  has  been  practised  repeatedly,  either  at  the  time  the 
operation  was  performed  or  later,  after  retraction  had  set  in.  but  the 


Fig.   628.— Chopart's   amputation    (von    Esmarch^  :     a,   Mediotarsal   joint;    l>,  line    of 
incisions  ;  c;  completion  of  plantar  flap  after  disarticulation. 

results  did  not  fulfil  the  expectations.  During  the  last  four  or  five 
years  I  have  succeeded  in  preventing  heel  retraction  b}-  sutiu-ing  the 
cut  flexor  and  extensor  tendons  over  the  head  of  the  astragalus  with 
a  row  of  strong  catgut  sutures.  As  an  aid  to 
the  tendon  sutures  I  have  supported  the  heel 
and  posterior  surface  of  the  leg  by  a  posterior 
plastic  splint,  or  applied  a  circular  plaster-of- 
Paris  .splint  over  the  dressing,  extending  from 
the  end  of  the  stump  to  the  knee. 

If  what  remains  of  the  foot  after  Chopart's 
di.sarticulation  is  held  in  proper  position  by 
these  mechanical  aids  until  the  tendon  ends 
are  firmly  united,  retraction  of  the  heel  will 
not  occur  and  the  patient  will  recover  with  a 
useful  limb.  Ankle-joint  motion  is  al.so  pre- 
served, adding  much  to  the  functional  result. 

The  line  of  disarticulation  is  at  the  junction 
of  the  astragalus  and  os  calcis  above  with  the 
.scaphoid  and  cuboid  bones  below.     The  line 
of  Chopart's  joint  is  found  at  the  outer  margin  of  the  foot,  about 
an  inch  above  the  tuberosity  of  the  metatarsal  bone  of  the  little  toe, 


I'tfr.  629.  —  Stinnp 
afirr  (Jhopnrl's  disnrlicii 
lation  (v(H)  Ksniarch). 


1094 


AMPUTATIONS    AND    DISARTICULATIONS. 


at  the  inner  margin,  half  an  inch  above  the  tuberosity  of  the  scaph- 
oid. These  two  points  must  be  carefully  located  and  marked  by 
indenting  the  skin  with  the  finger-nail  before  the  first  incision  is 
made.  The  long  plantar  flap  is  made  by  including  in  the  incision 
the  plantar  surface  between  the  two  points,  and  extending  it  as  far  as 
the  heads  of  the  metatarsal  bones,  round- 
ing off  the  free  end  of  the  flap  by  a  gentle 
curve  of  the  incision.  All  the  tissues  down 
to  the  bones  are  included  in  the  flap.  The 
foot  is  now  flexed,  and  the  two  points  are 
connected  on  the  dorsal  side  by  a  slightly 
curved  incision,  with  the  convexity  directed 
downward.  This  short  flap  includes  all  the 
tissues  down  to  the  extensor  tendons,  and 
is  reflected  as  far  as  the  line  of  disarticula- 
tion, when  a  second  incision  severs  the 
tendons  and  ligaments.  After  the  disar- 
ticulation has  been  completed  from  the 
dorsal  side,  the  plantar  flap  is  made  by 
cutting  from  above  downward,  closely  hug- 
ging the  plantar  arch.  Hemorrhage  being 
arrested,  the  principal  tendons  on  the  plan- 
tar and  dorsal  side  are  united  by  from  two 
to  four  strong  catgut  sutures.  The  wound 
is  drained  through  a  small  incision  in  the 
center  and  at  the  base  of  the  plantar  flap. 
Over  a  copious  dressing  the  fixation  splint 
is  applied,  as  previously  indicated.  Immo- 
bilization of  the  stump  must  be  continued  for  at  least  four  weeks, 
even  if  the  healing  of  the  wound  is  faultless. 

Malgaigne's  subastragaloid  disarticulation  by  two  lateral 
flaps  and  Syme's  amputation  through  the  ankle-joint  with  ex- 
cision of  the  malleoli  are  operations  no  longer  entitled  to  consider- 
ation in  a  modern  work  on  surgery,  as  amputation  of  the  leg  is  now 
almost  universally  recommended  for  pathologic  conditions  and  in- 
juries warranting  the  performance  of  either  of  these  operations. 

Pirogoff's  Amputation. — Pirogoff's  osteoplastic  calcaneotibial 
amputation  has  stood  the  test  of  time  and  is  deserving  of  our  con- 
fidence in  appropriate  cases.  The  stump  resulting  from  this  oper- 
ation enables  the  patient  to  walk  about  'and  follow  his  occupation 
without  any  mechanical  support  of  special  construction,  a  matter  of 
much  importance  in  patients  belonging  to  the  working-classes.  It 
is  in  every  sense  an  osteoplastic  procedure,  as  a  part  of  the  os  calcis 
is  preserved  and  becomes  later  a  part  of  the  fibula  and  tibia,  furnish- 
ing these  bones  with  a  new  epiphyseal  extremity  in  every  way  well 
adapted  to  support  the  weight  of  the  body  in  standing  and  walking, 
as  the  transplanted  part  of  the  os  calcis  is  furnished  with  a  thick 
elastic  cushion  of  soft  tissues  admirably  fitted  for  this  purpose.      I 


Fig.  630. — Suturing  of 
flexor  and  extensor  tendons 
after  Chopart's  mediotarsal 
disarticulation. 


PIROGOFFS    AMPUTATION'. 


1095 


have  performed  this  operation  five  or  six  times,  and  in  every  instance 
the  patient  was  able  to  walk  well,  without  crutches  or  cane,  in  less 
than  a  )ear. 

In  performing  the  operation  the  foot  is  held  at  a  right  angle, 
and  the  first  incision  is  made  down  to  the  bone,  across  the  plantar 
surface,  from  the  tip  of  the  external  malleolus  to  that  of  the  inter- 
nal malleolus.  The  foot  is  now  flexed  toward  the  plantar  side,  and 
the  second  incision  made  from  the  same  points  transversely  over  the 
anterior  aspect  ot  the  tibiotarsal  joint.  The  next  incisions  open  the 
ankle-joint  in  the  front  and  on  the  sides,  when  the  upper  surface  of 
the  astragalus  is  freely  exposed. 

After  the  astragalus  has  been  completely  dislocated,  the  foot  is 
depressed  sufficiently  to  bring  the  posterior  surface  of  the  bone  into 
view.  Immediately  behind  the  astragalus  the  os  calcis  is  divided 
with  the  saw  vertically  in  a  transverse  direction.      The  next  .step  of 


Fig.  631. — Pirogoff's  osteoplastic  calcaneotibial  amputation.     Section  of  os  calcis 
through  anterior  incision  (Wyeth). 


the  operation  consists  in  clearing  the  malleoli  and  resecting  them 
with  a  thin  slice  of  the  tibia.  The  tendo  Achillis  is  next  divided  trans- 
versely above  its  insertion,  and  the  skin  at  the  same  place  is  fenes- 
trated for  the  insertion  of  a  drain.  Giinther  has  modified  Pirogoff's 
amjjutation  by  dividing  the  os  calcis  obliquely  from  behind  forward 
and  downward,  and  Le  Fort  and  von  Bruns  remove  about  one-third 
of  the  vertical  diameter  of  the  bone  by  a  longitudinal  section  with  the 
saw.  The  plantar  flap,  including  a  part  of  the  os  calcis,  must  cover 
the  surface  of  the  wound  in  such  a  way  that  there  will  be  absolutely 
no  tension  after  snturing.  The  sawn  surfaces  of  the  tibia  and  fibula 
above,  and  of  the  os  calcis  below,  must  be  brought  into  accurate 
contact  and  immobilized  properly.  Suturing  of  the  flap  can  not  be 
relied  up(jn  in  accomf)lishing  this.  Tlie  bone  sin'faces  can  be  held 
in  accurate  and  uninterrupted  contact  by  resorting  to  silver-wire 
suture,  bone  or  ivory  nail,  or,  what    I    have   found   reliable  in   my 


1096 


AMPUTATIONS    AND    DISARTICULATIONS. 


practice,  by  suturing  the  extensor  and  flexor  tendons  with  two  or 
three  strong  catgut  sutures. 

As  extensive  bone  surfaces  always  give  rise  to  troublesome 
oozing,  drainage  in  this  operation  becomes  a  necessity.  The  most 
efficient  drainage  is  secured  by  tunneling  the  base  of  the  plantar 
flap  with  hemostatic  forceps,  and  making  an  opening  in  the  skin 
large  enough  to  insert  a  drain  the  size  of  the  little  finger.      On  the 

tibial  side  a  smaller  drain 
can  be  inserted  at  the 
angles  of  the  wound. 
Over  the  dressing  a  fix- 
ation splint  is  applied, 
and  special  attention 
paid  to  make  it  useful 
in  supporting  the  plan- 
tar flap. 

Amputation  of  the 
Leg.  —  In  all  amputa- 
tions of  the  leg  the  fu- 
ture utility  of  the  stump 
must  be  taken  into  care- 
ful consideration  before 
deciding  upon  the  site 
of  the  operation.  A  short 
St II J  up  is  desii'able  if  the 
patient,  for  financial  or 
other  reasons,  prefers  a 
peg-leg ;  a  stiunp  not 
less  than  four  inches  in 
leiigtJi  is  required  to  en- 
able the  patient  to  zualk 
with  the  aid  of  an  arti- 
ficial limb.  The  choice 
of  selectiojt  of  the  site  of 
ampntation  is  below  the 
tuberosity  of  the  tibia  for 
the  nse  of  a  peg-leg, 
while  amputation  at  the 
junction  of  the  middle 
with  the  lozver  third  yields  the  best  stump  for  the  wearing  of  an  arti- 
ficial limb.  The  leg  should  never  be  amputated  below  the  junction 
of  the  middle  zvith  the  lower  third.  Amputation  at  any  point  between 
the  two  places  of  election — that  is,  four  inches  belotv  the  knee  joint  and 
the  junction  of  the  middle  xvith  the  lower  third— yields  a  serviceable 
stiunp  for  the  comfortable  zv  earing  of  an  artificial  limb.  The  technic 
of  the  operation  is  the  same  whatever  anatomic  level  is  selected. 
Flap  formation  by  transfixion  has  largely  been  abandoned  in  favor 
of  cutaneous  flaps.    Circular  amputation  in  one  or  two  steps  should 


Fig.  632. — Pirogoff's  osteoplastic  calcaneotibial 
amputation  (von  Esmarch)  :  a,  Line  of  section  through 
tibia,  fibula,  and  os  calcis ;  b,  wound  surface  after 
amputation  ;  c,  stump  after  Pirogoff's  amputation. 


AMPUTATION    OF    THE    LEG. 


1097 


never  be  performed  below  tlie  knee-joint.  The  cutaneous  flaps  for 
reasons  advanced  elsewhere,  must  be  made  to  include  the  apo- 
neurotic sheath  of  the  muscles.  The  cutaneous  flaps  must  be  made 
of  unequal  length,  in  order  to  bring  the  line  of  suturing  and  the  ex- 
ternal scar  resulting  from  the  operation  away  from  the  ends  of  the 
bone. 

The  ideal  flap  formation  in  amputations  of  the  thio-h  and  leer 
consists  in  making  a  long  anterior  and  a  short  posterior  semduna" 
flap.  However.  ,t  the  nature  of  the  injurv  or  the  location  of  the 
disea.se  makes  it  desirable  to  reverse  the  procedure,  there  is  no  obiec- 
tionin  taking  the  long  flap  from  the  opposite  .side  or  in  making 
semilunar  lateral  flaps  of  unequal  length,  as  all  the.sc  deviations  from 
the  ideal  method  accomplish  the  same  object  in  bringing  the  line  of 
suturing  aw^ay  from  the  center  of  the  stump.  It  is  in  amputations 
ol  the  leg  and  thigh  that  it  is  so  extremely  important  to  cover  the 
end  of   the  bone  with  a  periosteal  flap  or  cuff",  so  as  to  interpose 


Kig.  633.-Ain,nitation  of  the  leg  at  the  junction  of  the  lower  with  the  middle  third 
Ideal  long  oval  anterior,  and  .short  oval  posterior,  flaps. 

between  the  flap  and  the  bone  the  normal  envelop  of  bone— the 
periosteum. 

As  the  same  principles  underlie  all  amputations  of  the  leg  and 
the  technic  differs  but  little  in  regard  to  the  level  where  the  opera- 
tion is  performed,  a  description  will  be  given  here  in  detail  of  an 
amputation  at  the  junction  of  the  middle  with  the  lower  third  in 
illustration  of  the  general  remarks  on  amputation.  We  will  take  it 
for  granted  that  the  nature  of  the  injury  or  the  location  of  the  dis- 
ease is  such  as  to  permit  flap  formation  b\'  tlu>  idral  method.  The 
hmb  is  held  in  the  extended  i)osition.  free  from  the  operating  table, 
and  on  a  level  suiting  the  cc^nvenience  of  the  surgeon.  TJie  ba.se' 
of  the  long  anterior  semilunar  flap  includes  one-half  of  the  circumfer- 
ence of  the  limb,  and  its  length  must  corres[)ond  with  two-thirds  of 
the  diameter  of  the  limb.  At  a  point  corre.sjxjnding  with  the  pro- 
po.sed  level  of  the  amputation  the  knife  is  entered  at  a  right  angle 
in  the  lateral  nn'dline  of  the  limb,  tm  the  side  away  from  the  opera- 
tor. The  inci.si(jn  is  carried  downward  until  it  is  within  an  inch  of 
the  low.rr  limits  of  the  flap,  when,  in  a  gentle  downward  curve,  it  is 


1098 


AMPUTATIONS    AND    DISARTICULATIONS. 


swept  across  the  anterior  surface  of  the  limb  to  the  opposite  side. 
Here,  in  a  similar  but  upward  curve,  it  reaches  the  midline,  and  the 
incision  is  extended  to  the  same  level  at  which  it  was  commenced. 
The  incision  is  made  deep  enough  to  cut  through  the  fascia  of  the 
extensor  muscles.  The  flap  must  be  detached  and  reflected,  with- 
out traction,  tearing,  or  violence  of  any  sort,  by  clean  cuts  of  the 
knife  directed  not  toward,  but  away  from,  the  flap.  As  soon  as  the 
dissection  has  reached  a  point  an  inch  below  the  proposed  level  of 
amputation,  the  periosteum  of  the  tibia  is  incised,  raised,  and  reflected 
with  the  cutaneous  flap.  The  posterior  flap,  about  one-third  the 
length  of  the  anterior,  is  made  in  a  similar  manner.  The  muscles 
are  cut  with  a  strong  scalpel  obliquely  from  below  upward  and  in 
the  direction  of  the  bones. 

After  the  bones  are  freed,  a  circular  incision  is  made  through 
the  periosteum  of  the  fibula,  which  is  then  reflected  to  the  distance 
of  an   inch  in  the  form  of  a  cuff      The  soft  parts  are  then  well  re- 


Fig.  634. — Amputation  surface,  showing  section  of  fibula  an  inch  above  the  level  of  that 
of  the  tibia  ;  periosteal  ilap  and  cuff  for  sawn  surface  of  tibia  and  fibula. 

tracted  by  the  hands  of  an  assistant  or  a  three-tailed  bandage,  and 
the  fibula  is  divided,  first  at  least  an  inch  above  the  proposed  line  of 
section  of  the  tibia.  This  modification  of  the  ordinary  method  of 
bone  section  was  first  recommended  by  Gouley,  of  New  York,  and 
Galbraith,  of  Omaha,  and  has  ever  since  been  followed  by  me  with 
the  most  gratifying  results,  as  it  materially  increases  the  degree  of 
conicity  of  the  stump. 

Section  of  the  tibia  must  be  made  in  a  manner  that  will  mini- 
mize the  use  of  the  bone-cutting  forceps.  The  spine  of  the  tibia  at 
the  end  of  the  bone  has  always  been  a  source  of  mischief.  It 
should  be  removed  with  the  saw  and  not  with  forceps,  and  should 
be  done  before  the  section  of  the  bone  is  completed.  The  first 
section  with  the  saw  is  made  through  the  spine  of  the  tibia,  obliquely 
from  above  downward  and  backward,  to  the  depth  of  an  inch  ;  the 
transverse  section  is  then  made  on  a  line  with  the  lower  terminus 
of  the  oblique  cut,  severing  first  the  wedge-shaped  piece  of  the 
spine.      On   completing  the  section  the  end  of  the   tibia   requires 


AMPUTATION    OF    THE    LEG. 


1099 


little,  if  an>-,  tiimniing  uith  the  bone  forceps.  The  principal  blood- 
vessels arc  now  tied,  and  the  nerve-ends  are  sought  for  and  resected 
before  the  Esmarch  constrictor  is  removed.  After  completion  of  the 
hemostasis  the  wound  is  drained  by  a  tubular  drain  passing  through 
a  buttonhole  in  the  posterior  flap  in  the  middle  and  at  its  base 
The  drain  should  not  reach  further  than  the  end  of  the  tibia  The 
question  whether  the  flaps  have  been  made  of  proper  length  must 
be  settled  after  the  amputation  has  been  made,  as  errors  in  this  con- 
nection must  be  remedied  at  this  time. 

The  first  step  in  the  suturing  of  the  wound  consists  in  bringing 
the  long  flap  in  position,  and  suturing  the  periosteal  flap  over  the 
sawn  surface  of  the  tibia  with  two  or  three  catgut  stitches.      The 
pcrio.steal  cuff  of  the  fibular  end   does  not  require   suturing,  as  it 
will  cover  the  end  of  the  bone  without  any  mechanical  aid^'    The 
next  row  of  strong  catgut  sutures  serves  as  a  temporarv  point  of 
anchorage   for  the    cut 
muscles.       The     flexor 
and    extensor    muscles 
are    sutured    over    the 
ends    of    the    bones, 
space   being   left  in  the 
flexors   for  the  tubular 
drain.      During    the 
whole  time  required  for 
suturing    and    dressing 
the'  stump  is  held  in  an 
elevated  position  by  an 
assistant,     who     grasps 
the  leg  with  both  hands 
below   the   knee,    mak- 
ing   at    the    .same   time 
downward    traction    on 
the    skin    and   muscles. 
As  a  rule,  tiot  enough  attention  is  paid  to  suturing  of  the  flaps.     The 
wound  margins  must  be  distributed  equally,   and  carefully  united 
by  deep  interrupted  sutures  of  silkworm-gut  or  silk  and  a  continued 
superficial  suture  of  horsehair.      To  do  this   will    require   time,  but 
unless  there  are  well-grounded  objections  to  painstaking  careful 
suturing,  this  must  be  done,  as  it  contributes  much  to  a  .speedy  and 
ideal  healing  of  the  wound.      The  best  needles  for  this  part  of  the 
suturing  of  the  amj)utation  wound  are  the  glover's  needles. 

The  interrupted  sutures — t7vo  or  three  to  CTcry  inch — must  include 
all  the  tissues  of  the  flap,  and  more  especially  the  aponeurotic  sheath 
of  the  muscles.  The  needle  punctures  must  be  the  same  distance  from 
the  wound  margin  on  both  sides  of  the  flap,  in  order  to  in.fure  accu- 
rate coaptation  and  to  avoid  harmful  linear  compression.  The  first 
suture  brings  together  the  center  of  the  two  flaps,  and  the  next  two 
equally   subdivide   each    li.ilf   of  the   wound   again,   thus  a.ssuring 


Jt*'?-  635. — Operation  completed.  Wound  drained 
through  a  Ijuttonhole  at  the  center  and  base  of  the 
posterior  flap. 


IIOO 


AMPUTATIONS    AND    DISARTICULATIONS. 


equal  distribution  of  the  wound  margins.  After  ail  the  interrupted 
sutures  are  in  place,  the  continued  horsehair  suture  brings  together 
the  skin,  which  is  usually  found  inverted  more  or  less  between  and 
underneath  the  sutures.  A  mouse-toothed  tissue  forceps  does  the 
most  efficient  service  in  picking  up  the  skin  preparatory  to  making 
the  punctures  with  the  needle.  As  a  ride,  the  sutures  are  tied  too 
tightly,  which  fact  often  accounts  for  the  marginal  necrosis  resulting 
from  the  interception  of  the  superficial  circulation.     The  sutures  must 

be  tied  only  with  sufficient 
firmness  to  bring  together 
and  hold  in  contact  the 
wound  margins,  carefully 
avoiding  tension.  The 
elasticity  of  the  horsehair 
suture  recommends  it 
very  strongly  for  the 
suturing  of  the  skin,  as 
it  adapts  itself  to  the  in- 
creased tension  caused  by 
the  slight  swelHng  of  the 
wound  margins,  so  con- 
stantly present  even  in 
aseptic  wounds. 

After  the  suturing  has 
been  completed,  the 
wound  is  sprinkled  with 
the  borosalicylic  powder 
until  the  sutures  are 
buried,  when  a  copious 
hygroscopic  aseptic  dress- 
ing is  applied,  embracing 
the  limb  as  far  as  the 
knee-joint.  A  gauze 
roller  should  always  be 
used  in  place  of  the  ordi- 
nary muslin  bandage,  as 
it  is  more  elastic,  besides 

Fig.  636.— Ideal  stump  after  amputation  of  the  leg.         constituting    a    valuable 

part  of  the  aseptic  dress- 
ing. The  roller  is  applied  in  such  a  way  as  to  support  efficiently 
the  flaps,  and  also  with  a  view  to  exercising  equable  compression, 
becoming  thus  an  important  aid  to  the  sutures  and  maintaining  un- 
interrupted coaptation  of  the  wound  surfaces.  The  thigh  is  wrapped 
in  common  cotton,  and  the  limb,  in  the  extended  position,  is  immo- 
bilized by  a  hollow,  well-padded  posterior  splint,  which  should  reach 
from  the  end  of  the  stump  to  the  ba.se  of  the  thigh.  After  the  am- 
putation the  limb  is  held  in  an  elevated  position  until  the  operation 
is  completed,  and  must  be  kept  at  an  elevation  of  at  least  45  degrees 


GRITTI-STOKES     AMPUTATION.  IIOI 

for  twenty-four  hours  or  longer.  The  importance  of  immobilization 
of  the  stump  by  an  appropriate  external  mechanical  support  should 
never  be  ignored,  for  its  influence  in  preventing  pain  and  undue 
muscular  retraction  and  its  value  in  aiding  the  process  of  repair  are 
in  no  instance  more  apparent  than  after  amputation  of  the  leg. 

Disarticulation  at  the  knee=joint,  a  favorite  operation  during 
the  preaseptic  period  of  operative  surgery,  has  passed  into  well- 
deserved  desuetude.  The  bulbous  shape  of  the  stump  that  results 
from  the  operation,  with  and  without  preservation  of  the  patella, 
is  detested  b\'  all  manufacturers  of  artificial  limbs.  Under  aseptic 
precautions  the  immediate  risks  to  life  are  not  greater  by  making  a 
supracondyloid  amputation  of  the  thigh  than  by  making  a  disarticu- 
lation at  the  knee-joint,  and  the  former  yields  a  serviceable,  the  lat- 
ter a  troublesome  or  almost  useless,  stump. 

Syme's  intracondj^loid  and  Garden's  transcondyloid  amputations 
have  done  something  toward  diminishing  the  size  of  the  bulb  at  the 
end  of  the  stump,  but  not  sufficiently  to  adapt  it  to  the  wearing  of 
an  artificial  limb  with  comfort.  The  teaching  and  practice  to  the 
effect  that,  in  the  operative  treatment  of  injuries  and  disease  that 
necessitate  an  amputation  at  or  near  the  knee-joint,  the  surgeon 
should  invariably  select  the  supracondyloid  level,  must  appear 
timely  and  rational.  Fortunately,  an  operation  has  been  devised  in 
this  location  by  Gritti,  and  modified  by  .Stokes,  that  answers  all 
anatomic  indications  for  making  an  ideal  stump  for  the  wearing  of 
an  artificial  limb. 

Gritti =Stokes'  Amputation. — Gritti  planned  and  described,  from 
an  anatomic  and  practical  standpoint,  one  of  the  most  nearly  perfect 
of  all  mutilating  operations.  He  proposed  to  saw  the  femur  through 
the  base  of  the  condyles  and  utilize  the  patella,  deprived  of  its  car- 
tilage, as  a  covering  for  the  end  of  the  bone.  Stokes  modifietl  the 
operation  by  advising  section  of  the  bone  above  the  cond\'les. 
The  operation  thus  modified  is  technically  called  supracondyloid 
osteoplastic  amputation.  This  operation,  of  course,  is  resorted  to 
only  in  cases  in  which  the  patella  itself  is  not  diseased.  I  have, 
however,  had  a  number  of  ca.ses  of  .synovial  tubcrculo.sis  of  the 
knee-joint  requiring  amputation  in  which  it  gave  most  excellent 
results.  The  long  anterior  oval  flap,  including  the  patella,  is  made 
by  entering  the  knife  about  an  inch  above  the  epicondyle  of  the 
femur,  on  the  side  opposite  to  the  operator,  after  which  the  flap  is 
outlined  in  the  .same  manner  as  in  amputation  of  the  leg  by  the 
.same  method  of  flap  formation.  The  incision  is  terminated  at  a 
point  vis-a-vis  to  where  it  was  commenced,  an  inch  above  the  oppo- 
site epicondyle.  In  reflecting  the  flap  the  tendon  of  the  patella  is 
severed  above  its  insertion,  and  the  tendcjn  and  patella  are  reflected 
with  the  flap.  ilie  short  oval  j)o.stenor  flap  is  ne.xt  made,  and,  as 
usual,  the  fibr(»us  sheath  of  the  flexor  mu.scles  is  included.  The 
circular  inci.sion  through  the  muscles  is  made  with  a  .stout  scalpel, 
and  in  such  a  marmer  that  after  tiie  amputation  the  tissues  under- 


II02 


AMPUTATIONS    AND    DISARTICULATIONS. 


neath  the  skin   resemble  a  shallow  cup,  the  deepest  portion  corre- 
sponding to  the  end  of  the  femur. 

As  the  superficial  muscles  retract  much  more  than  those  near 
the  bone,  the  incision  through  the  muscles  must  be  made  very 
oblique,  so  as  to  place  the  soft  tissues  of  the  amputation  wound  in 
the  best  possible  condition  for  suturing,  and  to   give  the  desired 


Fig.  637. — Gritti-Stokes'  supracondyloid  osteoplastic  amputation.     Flap  formation. 

shape  to  the  stump.  The  section  through  the  soft  tissues  is  made 
on  a  line  with  the  base  of  the  condyles.  As  soon  as  the  bone  is 
reached  the  periosteum  is  divided  by  a  separate  circular  cut,  and 
reflected  with  the  periosteal  elevator  in  the  form  of  a  cuff,  to  a  dis- 
tance of  at  least  an  inch.  The  periosteum  must  remain  attached 
to  the  adjacent  tissues,  and  no  attempt  must  be  made  to  form  a 

separate  perios- 
teal flap  or  cuff 
The  bone  is 
divided  with  a 
saw  j  ust  above 
the  condyles, 
transversely  to 
its  long  axis. 
During  this  step 
of  the  operation 
the  soft  tissues 
are  carefully  re- 
tracted by  the 
hands  of  an  as- 
sistant or  by  the 
use  of  a  retrac- 
tor made  of  gauze.  Unless  splintering  takes  place  toward  the  end 
of  the  section,  the  end  of  the  bone  does  not  require  the  use  of  the 
bone  forceps.  The  line  of  section  through  the  bone  must  be  above 
the  condyles,  but  should  not  open  the  medullary  canal.  After  the 
amputation  has  been  made,  the  long  flap  is  brought  into  position, 
and  if  any  defect  in  flap  formation  is  detected,  it  must  be  remedied 
at  this  time.      If  this  part  of  the  operation  has  been  found  satisfac- 


Fig.  638. — Removal  of  articular  surface  of  patella  with  saw. 


GRITTI-STOKES     AMPUTATION. 


I  103 


tory,  the  under  surface  of  the  patella  is  vivified  by  excising  with 
the  saw  its  under  cartilaginous  surface. 

Perhaps  the  most  difficult  part  of  the  operation  consists  in  unit- 
ing the  vivified  patella  securely  with  the  end  of  the  femur.  Direct 
means  of  fixa- 
tion arc  essential 
in  accoviplishing 
tJds  object.  Sev- 
eral means  of 
direct  fixation 
of  the  patella 
against  the  end 
of  the  f e  m  u  r 
suggest  them- 
selves. A  sil- 
ver-wire suture 
embracing  the 
lower  margin  of 

the    patella     and  ^'S*  ^^9- — Fixation  of  vivified  patella  against  sawn  surface 

, ,  ^       of  femur  with  ivory  nail,  and  suturing  of  flexor  muscles  to  the 

the    COmpacta  ot       patellar  tendon. 

the    posterior 

margin  of  the  end  of  the  femur  will  secure  accurate  coaptation  of 
the  bone  surfaces  and  permanent  fixation  of  the  patellar  fragment. 
In  the  absence  of  bone  or  ivory  nails  this  method  of  fixation  has 
much  to  recommend  it.  The  ideal  method  of  fixation  is  by  the  use 
of  an  absorbable  aseptic  bone  or  ivor\'  nail.  The  patella  is  per- 
forated near  its  lower  margin  with  a  drill,  when  an  ivory  or  a  bone 

nail,  an  inch  and 
a  half  in  length, 
is  inserted,  and, 
after  the  patella 
is  in  proper 
place  directly 
over  the  end  of 
liie  femur,  is 
driven  its  entire 
length  into  the 
.spongy  tissue  of 
this  bone.  The 
projecting  por- 
tion of  the  nail 
on  the  outer 
s  u  r  fa  c  e  of  the 
patella  is  cut  off  on  a  level  uitii  the  bone  with  bone  forceps,  so  that 
this  end  u{  the  nail  is  covered  by  piriosteum.  As  an  acklitional  aid 
the  tendon  of  the  patella  is  sutured  with  strong  catgut  to  the  llexor 
muscles.  I  have  resorted  to  this  method  of  fixation  of  the  patella 
in  a  number  of  cases,  and  have  found  it  absolutely  reliable.    I-'urther, 


Fig.  640. — Operation  com[)lclfd. 


II04  AMPUTATIONS    AND    DISARTICULATIONS. 

the  nails  never  caused  any  untoward  symptoms  and  were  always 
removed  by  absorption.  Should  suppuration  set  in  after  the  use 
of  bone  or  ivory  nails,  they  will  become  foreign  substances,  and 
their  removal  spontaneously  or  by  operative  interference  must  pre- 
cede the  final  healing  of  the  wound. 

The  third  and  simplest  method  of  fixation  of  the  patella  is  by 
suturing  of  its  tendon  to  the  flexor  muscles  with  at  least  three  strong 
catgut  sutures.  I  have  resorted  to  this  expedient  a  number  of  times 
with  entirely  satisfactory  results,  except  in  the  last  case.  In  this 
instance  suppuration  of  the  wound  loosened  the  anchorage  by  the 
catgut  sutures  prematurely,  and  the  patella  became  displaced  and 
attached  to  the  side  instead  of  the  end  of  the  femur.  This  single 
failure  is  perhaps  not  sufficient  ground  for  abandoning  the  catgut 


Fig.  641. — Stump  after  Gritti-Stokes'  supracondyloid  amputation. 

suture  as  a  sole  means  of  fixation  in  such  cases,  but  it  has  made  me 
more  partial  to  the  use  of  absorbable  aseptic  nails. 

The  suturing  of  the  flaps,  dressing,  and  fixation  of  the  stump 
are  the  same  as  after  amputation  of  the  leg.  The  stump  after 
Gritti-Stokes'  amputation  is  conic,  the  end  of  the  femur  rounded 
by  the  patellar  fragment,  which  has  become  a  part  of  the  bone. 
The  tissues  over  the  end  of  the  bone  are  freely  movable,  and  the 
bursa  of  the  patella  does  excellent  service  when  the  patient  begins 
to  wear  an  artificial  limb.  Patients  should  be  warned  not  to  make  an 
attempt  to  ivear  an  artificial  limb  for  at  least  a  month  after  the  wound 
has  healed.  Every  stinnp  must  be  properly  prepared  for  the  wearing 
of  an  artificial  limb.  This  preparatory  treatment  consists  in  system- 
atic firm  bandaging  to  expedite  the  physiologic  atrophy  that  always 
takes  place,  and  in  washing  the  skin  with  a  50  per  cent,  solution 
of   alcohol    to    make    it    more    tolerant   to   the   many   sources    of 


AMPUTATION    OF    THE    THIGH. 


I  105 


irritation  to  which  it  will  be  exposed  in  the  wearing  of  an  artificial 
limb. 

Amputation  of  the  Thigh. — The  same  rules  that  have  been 
laid  down  for  amputation  of  the  leg  are  applicable  and  in  force  in 
amputating  the  thigh  above  the  Gritti-Stokes  line.  Cutaneous  semi- 
lunar flaps  ot  unequal  length  are  always  to  be  employed  as  a  cover- 
ing for  the  amputation  wound.  The  deep  incisions  must  be  very 
oblique,  as  the  powerful  superficial  muscles  of  the  thigh  retract  phe- 
nomenally in  spite  of  all  precautions.  The  end  of  the  femur  must 
always  be  furnished  with  a 
periosteal  covering  in  the 
form  of  a  cuff!  Muscle  su- 
ture is  of  immense  import- 
ance in  minimizing  retraction 
and  in  guarding  against  pain- 
ful muscular  twitching  by 
furnishing  the  cut  muscles 
with  a  temporary  point  of 
anchorage.  Muscle  suture 
is  made  with  strong  catgut 
in  the  form  of  a  transverse 
row  of  sutures  over  the  end 
of  the  bone,  uniting  the  ex- 
tensor and  flexor  muscles. 
Drainage  is  always  estab- 
lished through  a  separate 
opening  in  the  most  depend- 
ent part  of  the  wound.  The 
flaps  are  to  be  sutured  with 
the  utmost  care,  and  the 
stump  is  dressed  and  immo- 
bilized as  in  amputation  of  the  leg.  Even  a  short  stump  enables 
the  patient  to  walk  with  the  aid  of  an  artificial  limb  of  special  con- 
.struction. 

When  the  question  arises  as  to  the  advisability  of  making  a  dis- 
articulation at  tiic  hip-joint  or  a  high  amputation  of  the  thigh,  the 
surgeon  must  not  forget  that  the  immediate  risks  of  the  operation 
are  really  greater  in  a  disarticulation  than  in  a  high  amiJiitation,  and 
his  decision  and  action  must  be  governed  accordingly. 

Disarticulation  at  the  hip-joint  has  been  discussed  in  the 
chapter  on  I'roph)  lactic  Ilemostasis. 


Fig.    642. — Atrophy  of  phalanx    in    stump  of 
finger  after  amputation. 


70 


INDEX. 


Abbe's  needle-holder,  2 1 1 
Abdomen,  gunshot  wounds  of,  273 
diagnosis,  277 
drainage,  284 
hemorrhage  from,  280 
hydrogen-gas  insufflation  in, 

incision  for,  280 
irrigation  after,  283 
laparotomy  for,  274,  279 
after-treatment,  285 
preparation  of  patient,  279 
recover^'  from,  without  inter- 
ference,   274 
suturing,  283 
symptoms,  276 
treatment,  278 
tapping  of,   624 
Abdominal  abscess,  intestinal  fistula 
from,  1008 
cavity,  drainage  of,  687 
irrigation  of,  283 
ligamentous  bands  in,   873 
operation,  intestinal  fistula  from, 

1009 
section,  770 

and    iodoformization    for   intes- 
tinal tuberculosis,   945 
anesthesia  in,  775 
antiseptics  in,  774 
atropin   in,    775 
corrosive  sublimate  in,  774 
early  performance  of,  772 
examination  of  intestine,  778 
for  strangulation,  770 
hemorrhage  in,  777 
in  fibrinoplastic  peritonitis,  699 
incision,  776 

intestinal  obstruction  after,  980 
intra-abdominal  examination  in, 

777 

mortality,  771 

preparations,  774 

requirements  of  surgeon,  773 

statistics,  770 

sterilization  of  room,  etc.,  774 

temperature  of  room,  774 
taxis  for  volvulus,  857 

in  obstruction  of  intestine.  755 
Abscess,  abdominal,  intestinal  fi.stula 

from,  1008 
cavity,  drainage   of,    in   intestinal 

fistula,  10 1 5 
in  cavum  Retzii.  676 


Abscess,  intestinal  fistula  from,  1006 
of  brain,  traumatic,  trephining  for, 

256 
pelvic,  intestinal  fistula  from,  1008 
peritoneal,  676 
subphrenic,  704 

tubercular,  intra-articular  medica- 
tion after,  626 
Acetate  of  aluminum  as  antiseptic, 
187 
solution,  202 
Actinomycosis,       intestinal      fistula 

from,  1008 
Acupressure,  131 

Adhesions  in  hernia,  removal,  995 
intestinal,  866,  870 
prognosis,  871 
Agnew's  splint,  373 
Air-passages,   emergency  operations 

on.  640 
Akidopeirasty,  341,  488,  592 
Alcohol  as  antiseptic,  188 
as  hand  disinfectant,  188 
for  sterilization  of  catgut,  no 
Amputations,    1059.      See   also   Dis- 
articulations. 
above  wrist-joint,  1069 
aims  of,  1065 
at  hip-joint,  bloodless,  73 

Senn's,   77 
at  wrist-joint,   1085 
bone  section  in,  1076 
by  transfixion,  1073 
Chopart's,  1092 
circular,    1073,    1074 
in  two  steps,  1075 
covering    sawn    surface    of    bone 

after,  1076 
cutaneous  flajis  in,  1079 
drainage  after,   107S 
emergency,  1070 
flaj)  formation,  1072 

including  deep  tissue  in,  1074 
for  atrophy,  1065 
for  carcmoma,  1064 
for  crushing  of  bones,  106  x 
for  gangrene,  1062,  1063.    See  also 

6'a  H^'rf>u'. 
for  malignant  tumors    ?nr>| 
for  paralysis,  1065 
for  sarcoma,   1065 
for  septicopyemia,   1062 
for  suppuration,  1063 
for  tearing  of  muscles,  1061 


1 107 


iio8 


INDEX, 


Amputations  for  tearing  of  nerves, 
1061 
of  skin,  1 06 1,  1063 
of  vessels,   1061 
Gritti-Stokes',  iioi 
Giinther's   modification    of    Piro- 

goff 's,  1095 
hemostasis  after,  1077 
in  war,  254 
indications  for,  1060 
instruments  for,   107 1 
Langenbeck's  oval  flap,  1080 
Le    Fort's    modification    of    Piro- 

goff's,  1095 
ligation  of  blood-vessels  after,  1077 
Listen's  oval  flap,  1080 
manual  compression  in,  1077 
musculocutaneous,  1081 
neuroma,  1066.   See  3I50  Neuroma. 
nontraumatic,  indications  for,  1063 
of  appendix,  730 
of  arm,  1085,  1086 

drainage,  1088 
of  fingers,  1069,  1082,  1083 
of  forearm,  1085 
of  great  toe,  1090 
of  hand,  1084 
of  leg,  1096 

suturing  wound,  1099 
of  lower  extremity,  1089 
of  thigh,   1097,   1 105 

site  for,  1066 
of  toes,  1089 
of  upper  extremity,  108 1 
oozing  after,   1077 
osteophytes  after,  1076 
peritoneal  flap  in,  1076 
Pirogoff's,   1094 
plastic    operations    as    substitutes 

for,   1062 
preparations  for,    1070 
primary,  indications  for,  1061 
removing  of  constrictor  after,  1077 
secondary,  indications  for,  1062 
site  of  operation,   1065 
Smith's  oval  flap,  1080 
stump,  care  of,  1077 

dressing  of,  1079 

immobilization  of,   1079 
suturing  of  wound,   1078 
Syme's,  through  ankle-joint,  with 

excision  of  malleoli,  1094 
Teale's  square  flap,  1080 
technic,    1065 
through  metatarsus,  1091 
von  Bruns'  flap,  1080 

modiflcation  of  Pirogoff's,  1095 
Anastomosis  button.  Murphy's,  789 
end-to-end,   819 

intestinal,     783.      See    also    Intes- 
tinal anastomosis. 
Anesthesia,  accidents  during,  50 
artificial  respiration  in,  53 
asphyxia  in,  51 
chloroform,  44 

death  from,  54 


Anesthesia,  dilatation  of   pupils   in, 

49 
ether,  56 

food  in  air-passages  in,  51 
general,  40 

heart  depression  in,  55 
in  emergency  surgery,  43 
in  laparotomy,  775 
in  tracheotomy,  647 
infiltration,  59 
local,  40,  58 

history,  58 
preparations  for,  45 
restoration  of  respiration  in,  51,  52 
signs  in,  49 
stage  of  excitement,  49 

of  tolerance,  49 
statistics,  41 
talking  partial,  43 
vomiting  in,  50 
Anesthetic,  administration  of,  41,  47 
chloroform  as,  42,  44 
ether  as,  42,  56 
local,  cocain,  60 

ethyl  chlorid,  59 

eucain,  61 

ice  and  salt,  58 

sulphuric  ether  spray,  58 
mixed,  43 
selection  of,  42 
Aneurysm,  traumatic,  from  modern 

bullet,  228 
Angiotribe,  88 
Angiotripsy,  89 
Ankle-joint,  drainage  of,  631 
resection  of,  1045 

incision  for,  1045 

temporary  resection  of  malleoli 
in,   1047 
Syme's  amputation  through,  with 

excision  of  malleoli,  1094 
Ankylosis,     angular,     resection    for, 

1026 
of  joints,  394 
Anostosis,   eccentric,   fractures   and, 

313 
Antipyogenic  agents,  184 
Antipyrin  as  styptic,  134 
Antiseptic  irrigation,  permanent,  565 
pomade,  204 
powders,  203 

borosalicylic,  204 

iodo form-boric,  204 
salves,  204 

boric  acid,  204 

borosalicylic,  204 

chloral  hydrate,  204 

unguentum  Crede,  205 
solutions,  198 

acetate  of  aluminum,  202 

aqua  binelli,  203 

bichlorid  of  mercury,  201 

boric  acid,  202 

carbolic  acid,  201 

chlorid  of  zinc,  203 

permanganate  of  potash,  203 


INDEX. 


I  109 


Antiseptic    solutions,     preparations 
for  use  of,  199 
saline,  203 
Thiersch's.  202 
Antiseptics,  186 

acetate  of  aluminum,  187 

alcohol,  1 88 

bichlorid  of  mercury,  191 

boric  acid,  1S8 

bromin,  188 

camphor,  189 

carbolic  acid,  189 

chloral  hydrate,  190 

chlorid  of  lime,  190 
of  sodium,  190 

chromic  acid,  191 

corrosive  sublimate,  191 

creasote,  192 

creolin,  192 

formaldehyd,  192 

formalin,    192 

formic  aldehyd,  192 

hydrogen  peroxid,  194 

in  laparotomy,  774 

iodin,  194 

iodoform,  194 

juniper,  196 

lysol,  196 

Peruvian  balsam.  196 

potassium  permanganate,  197 

resorcin,  197 

salicylic  acid,  197 

salol,  197 

sulphurous  acid,  197 

thymol,  197 

tinctura  benzoini  composita,  198 

turpentine,  198 
Antitoxin,  hydrophobia,  186 

syringe,  6^5 
Anus,  artificial,   765,   76S.      See  also 

Intestinal  fistula. 
Aorta,  manual  compression  of,  82 
Appendicitis,  705 

abscess  formation  in,  733 

age  and,  711 

amputation  in,  230 

bacillus  coli  communis  and,  710 

bur^'ing  of  stump,  732 

catarrhal,  713 
cccitis  and,   710 

diagnosis,  720 
difTerential,  722 

diagnostic  symptoms,  722 

diet  in,  724 

drainage,   732 

in    intermediary    operation    for, 

73.S 
dressing  after  operation,  733 
etiology,  707 
fecal  concretions  and,  71 1 
foreign  bodies  and,  71 1 
gangrenous,  719 
in  Spani.sh-American  war.  711 
intestinal  distention  in,  734 

fistula  from,  1008 
laxatives  in,  725 


Appendicitis,     McBumey's    muscle- 
spHtting  operation  for,  726 
point  in,  721 
microbic  production  of,  709 
muscular  rigidity  in,  721 
obliterans,  714 
age  and,  717 

inflammatory  origin,  718 
morbid  anatomy,  718 
patholog}-,  718 
syinptoms,  717 
operations  for,  early,  726 
intermediate,  733 
late,  735 
opium  in.  735 
pain  in,  720 
palpation  in,  721 
patholog}',  712 
perforative,  71S 
peritonitis  and,  714,  718 

treatment,  702 
position  in,  733 
progressive  septic  peritonitis  with, 

733 
quieting  peristalsis  in,  725 
relapsing,  719 

operation  for,  736 
subserous  enucleation  for,  736 
when  to  operate,  736 
symptoms,  720 
temperature  in,  722 
tenderness  in,  721 
treatment,  701,  723 
medical,  724 
operative,  725 
ulcerative,  713 
Appendix,  abnormalities,  706 
amputation  of,  230 
blood  supply,  706,  710 
location,  706 
obstruction  and,  876 
size,  706 

stump  of,  burying  of,  732 
suturing  of,  730 
Aqua  binclli,  203 
Arm,  amputation  of,  1085,  1086 
drainage,   1088 
suspender  constriction  of.  68 
Arteries,  gunshot  wounds  of,  290 
percutaneous    temporary    ligation 

of,  87 
preliminary    ligation    of,    in    con- 
tinuity, 85 
suture  of,  1 23 
temporary  ligation  of,  86 
tying  of,  in  etjiitinuity,  1 15 
Artery  forcej)s,  Halstcd's,  112 

obliterated,  cross-section  of,  104 
Arthrectomia  synovialisct  ossis,  1026 
Arthrectomy,  1026 
Arthrodesis,  resection  for,  1026 
Artificial  anus,  765,    768.     See  also 
Intestinal  fistula. 
respiration,   53 
Ascarides,  intestinal  obstruction  by, 
922 


mo 


INDEX. 


Ascending  colon  and  cecum,  tuber- 
culosis of,  955 

Ascites,  tapping  for,  624 
tubercular,  697 

Aseptic  catheterization,  632 

Aspiration  drainage,  654 

Ataxia,  locomotor,  fractures  and,  313 

Atresia,  congenital,  anastomosis  in, 

789 

of  intestine,  congenital,  925 
Atrophy  after  fracture,  396 

amputation  for,  1065 

bone,  fractures  due  to,  312 

inactivity,  312,  327 

joint  resection  and,  1032 

of  phalanx  in  finger  stump  ,1105 
Autotransfusion,  136 

in  gunshot  hemorrhage,  251 
Autotransplantation  of  bone,  529 
Avicenna's  reduction  of  subcoracoid 

dislocation,  594,  595 
Axillary  artery,  ligation  of,  1087 
rupture  of,  in  reduction,  586 


Bacillus    coli    communis    and    ap- 
pendicitis,  710 
intestinal  ulceration  and,  941 
peritonitis  and,  671 
of  tuberculosis  in  feces,  941 
peritonitis  and,  671 
wound  infection  with,  164 
pyocyaneus,  159 
tetani,  159 
Bacteria  on  body,  169 
Bacteriology  of  infection,  157 
Bands,    ligamentous,    in    abdominal 
cavity,  873 
location  of  formation  of,  875 
obstruction  b5^  872 

fecal  extravasation  in,  876 
operating  for,  875 
Bardeleben's  pelvic  supports,  462 
Bardenheuer's     suprapubic    incision 

of  bladder,  299 
Barker's  resection  of  intussusceptum, 

909 
Bassini's  operation  for  inguinal  her- 
nia,  lOOI 
Bayer's  case  of  irreducible  ileocolic 

invagination,  906 
Bedoin's  first-aid  package,  233 
Beely's  plaster-of- Paris  hemp  splint, 

38s 
Bergmann's    method    of    sterilizing 
catgut,  no 

plaster  bandage  saw,  552 
Bernay's  sponge,  179,  180 
Bezoars,  920 

Bichlorid  of  mercury,  191,  201 
Bircher's  fixation  method,  536 
Bladder,  infection  of,  from  catheter- 
ization, 633 

puncture  of,  627 

structure  of,  634 

urinary,  gunshot  wounds  of,  297 


Bladder,  uninary,  perforation  of,  297, 
298 
rupture  of,  297-299 
suprapubic  incision  of,  299 
wounds  of,  297 
treatment,  300 
Blasius'    modified    Dupuytren's    en- 

terotome,   10 16 
Bloodless  amputation  of  hip-joint,  73 
method  of  bone  implantation,  1052 
operations,  65 
reduction,  582 
suture,   212 
Blood-vessel,  ligation  of,  99 
after  amputation,  1077 
Boeckmann's  sterilizer,  175,  176 
Bone,  autotransplantation  of,  529 
crushing  of,  amputation  for,  1061 
decalcified,     1050.      See    also    Im- 
plantation. 
drainage-tubes,  215 
fate  of  foreign  material  in,  539 
ferrule,  fixation  by,  540 

sterilization,  541 
fragments,  fate  of,  539 
hemorrhage  from,  134 
nails,  immobilization  by,  468 
restoration  of,  357 
section  in  amputation,  1076 
suture,  531 

technic,  533 
transplantation  of,  361,  408,  409 
Bone-cutting  forceps,  1028 
Bone-plates,  preparation,  828 

uniting  intestine  by,  784 
Bone-production    from    periosteum, 

353.  355 
Bony  union  after  extracapsular  frac- 
tures, 446-450 
after     intracapsular     fractures, 

456 
time  required  for,  417 
validity  of  specimens,  451 
Boric  acid  as  antiseptic,  188 
ointment,  Lister's,  204 
solution,  202 
Borosalicylic  ointment,  204 

powder,  204 
Bracketed  splints,  553 
Brain,  abscess  of,  traumatic,  256 
Brainard's  bone  drills,  406 
Bridge  plaster-of- Paris  splint,  548 
Bromin  as  antiseptic,  188 
Bruns'  chisel,  1029 

double  metallic  nail,  535 
flap  method,  1074,  1080 
modification   of   Pirogoff's   ampu- 
tation,  1095 
spoon,  1029 
Brushes,  care  of,  168 
Bryant's  test-line,  443,  444 
Buchanan's  application  of  plaster-of- 

Paris  splint,  547 
Biilau's  aspiration  drainage,  655 
Bullet,  leaden,  deformities,  221 
Mauser,  effect  on  tissues,  218 


INDEX. 


nil 


Bullet,  searching  for,  222 
small-caliber,  effect  of,  555 
on  tissues.  21S 
jacketed,  deformities,  221 
wounds  from,  241 


Calculi,  intestinal  obstruction  from, 

914 
Callus,  definitive,  352,  354 
formation,  defective,  390,  392 
diastasis  and,  394 
suppuration  and,  393 
excessive,  390 
painful,  400 
production,  351 
provisional,  352,  354 
Camphor  as  antiseptic,  189 
Capillary    and    tubular    drainage    of 
abdominal  cavity,.  690 
drain,  217 

drainage  of  abdominal  cavity,  689 
Carbolic  acid  after  tapping  of  joints, 
626 
as  antiseptic,  189 
intoxication  by,  189 
solution,  201 
Carcinoma,  amputation  for,  1064 
fractures  and,  317 
intestinal  fistula  from,  1007 
obstruction  from,  970 
Catarrhal  appendicitis,  713 

synovitis,  tapping  for,  626 
Catgut  as  ligature,  106 
sterilization,  107 
alcohol,  no 

Bergmann's  method,  no 
formalin  method,  108 
Hofmeister's  method,  108 

Senn's  modification,  109 
Johnston's  method,  iio 
Kocher's  method,  no 
Cathartics  in  peritonitis,  679 
Catheter  case,  papier-mach6,  638 
Catheterization,  a.septic,  632 
for  intestinal  fistula,  1014 
in  private  practice,  639 
infection  from,  633 
technic,   637 
Catheters,  633,  635 
lubricant  for,  638 
sterilization,   638 
Cautery,  actual,  128 
Cavum  Retzii,  abscess  in,  676 
Cecal  tuberculosis,  933 
Cecitis,   catarrhal,  appendicitis  and, 

710 
Cecum  and  ascending  colon,   tuber- 
culosis f)f,  955 
resection  of,  for  tuberculosis,  949 
tuberculosis  of,  951 
tumor  of,  enterectomy  for,  798 
Chain  saw,  1030 
Chest,  gunshot  wounds  of,  261 
care  of  patients,  271 
cases,   262-267 


Chest,  gunshot  wounds,  hemorrhage, 
271 
treatment,  270 
ultimate  results,  266 
tapping  of,  622 
Chloral  hydrate  as  antiseptic,  190 

ointment,  204 
Chlorid  of  lime  as  antiseptic,  190 
of  sodium  as  antiseptic,  190 
of  zinc  as  antiseptic,  190 
solution,  203 
Chloroform,  44 
anesthesia,  42,  44 
death  from,  54 
narcosis  in  children,  43 
Chopart's     mediotarsal     disarticula- 
tion,  1092 
Chromic  acid  as  antiseptic,  191 
Cicatrix,     intravascular,     formation 

of,   104 
Cicatrization,  155 

Circular    amputation,     1073,     1074. 
See  also  Amputation. 
enterorrhaphy,  819.     See  also  En- 

terorrhaphy,  circular. 
plastic  splints,  550,  552 
Circulation,     embarrassed,    in    frac- 
ture dressing.  551 
Circumflex  artery,  tearing  of,  in  re- 
duction, 586 
Circumscribed  peritonitis,  673 
Clamps,  intestinal,  800 
ivory,  536 
metallic,  535 
Clavicle  and  scapula,  exarticulation 
of,  with  upper  extremity,  1088 
fractures  of,  treatment,  374 
Cocain  as  anesthetic,  60 
Cocci,  morphology,  158 
Cohen's  tracheotomy  tubes,  647 
Cold  as  hemostatic,  131 
Colles'  fracture,  475.     See  also  Frac- 
tures. 
Colon,  ascending,  and  ceciun,  tuber- 
culosis of,  955 
distention   of,   with   fluids,   in   ob- 
struction, 748 
objections  to,  750 
intussusception  of,  888 
stenosis  of,  colostomy  for,  765 
Colorectostomy,  840 
Colostomy,  765 
after  volvulus,  864 
closing  of  artificial  anus,  768 
drainage  in,  768 
for  intussusception,  900 
indications,   768 
inguinal,  left,  Maydl's,  767 
Knic's,  769 

moflern  operation,  766 
Colotomy,    764 
Compression,  fligital,  84 

for  hemorrhage  on  field,  24b 
clastic,  65 

in  wounrl  healing,  214 
manual,  82 


1 1 12 


INDEX. 


Concretions,  fecal,  appendicitis  and, 

711. 
intestinal,  920 
Conic  elastic  web  catheter,  635 
Constricting  ring,  cutting  of ,  995 
Constriction,  elastic,  applying  of ,  71 
at  hip-joint,  73 
at  shoulder-joint,  81 
for  hemorrhage  on  field,  244 
in  arm  amputation,  10S6 
in  emergency  surgery,  77 
in  prophylaxis,  64 
of  head,  81 
of  limbs,  66 

duration,  68 
of  skull,  81 
paralysis  after,  70 
removal  of,  7  2 
sequelae  of,  70 
special  localities  for,  73 
suspender,  of  arm,  168 
Constrictor,  elastic,  application,  66 
Corrosive    sublimate    as    antiseptic, 
191 
in  laparotomy,  774 
intoxication,   191 
solution,  201 
Craniectomy    in    hemorrhage    from 
middle  meningeal  artery,  502 
in  war,  254 
Creasote  as  antiseptic,  192 
Creolin  as  antiseptic,  192 
Crepitation,  fractures  and,  342 
Crural    canal,     Salzer's    method    of 

closing,  1004 
Cuba,  chest  injuries  in,  269 

gunshot  wounds  in,  229 
Cushing's     right-angled     continuous 

suture,  815 
Cutaneous  flaps,  1079 
Cylindric  elastic  web  catheter,  635 
Cystitis,  exciting  causes,  636 

predisposing  causes,  636 
Cysts,  fractures  and,  318 

intestinal  obstruction  by,  967 
Czerny  suture,  816 

in  circular  enterorrhaphy,  819 
Czerny-Lembert  suture,  814 


Debridement  in  gvmshot  fractures, 

554  . 
Decalcified  bone,  1050.      See  also  Itn- 

plantation. 
Decubitus,  fractures  and,  399 
Delayed  union,  400 

apparatus  for,  406,  407 
treatment,  403 
Delirium  traumaticum  and  fracture, 
399 

tremens  and  fracture,  399 
De  Vilbiss  bone-cutting  forceps,  500 
Diaphragmatic  peritonitis,  665 
Diarrhea,       intestinal       obstruction 

after,    980 
Diastasis  and  callus  formation,  394 


Dieffenbach's    operation    for    intes- 
tinal fistula,  1017 
Diffuse  septic  peritonitis,  667,  672 
Disarticulation,  1059.      See  also  Am- 
■pvitations. 

at  elbow-joint,  1085 
at  hip-joint,  1 105 
at  knee-joint,  iioi 
at      metacarpophalangeal      joint, 

1084 
at  metatarsophalangeal  joint,  1090 
at  shoulder-joint,  1086 
at  wrist-joint,  1085 
Lisfranc's  tarsometatarsal,  1092 
Malgaigne's  subastragaloid,  1094 
mediotarsal,    1092 
of  all  toes,  1 09 1 
of  fingers,  1082 
of  great  toe,  1090 
of  thumb,  1083 
Disinfection  of  field  of  injury,  173 

of  operation,  173 
of  hands,  169 

Kiimmel's  method,  171 

turpentine  in,  172 
of  mucous  surfaces,  174 
Disinvagination,  904 
Dislocations,  568 
age  and,  569 
deformity  in,  576 
deviation   of   shaft   of   bone   from 

normal,  577 
diagnosis,  578 
etiology,  569 
exciting  causes,  570 
fracture  and,  575 
intracoracoid,  587 
mechanism,  569 
of  both  bones  of  forearm,  600.    vSee 

also  Forearm. 
of     elbow-joint,      599.     See     also 

Elbow-joint. 
of  forearm.      See  Forearm. 
of  hip-joint,  598 

of  neck  of  femur,  fracture  and,  599 
of  radius,  610.      See  also  Radms. 
of  shoulder-joint,  586.        See  also 

Shoulder-joint. 
of  ulna,  609 
old,  574 
pain  in,  578 
recent,   574 

pathology,  571 
reduction  of,  580 

accidents  of,  585 

by  bloodless  method,  582 

by  manipulation,  582 

by  open  method,  584 

fracture  during,  585 
retroglenoid,   597 
rupture  of  nerves  in,  574 

of  vessels  in,  574 
shortening  in,  578 
subacromial,   597 
subclavicular,   587 
subcoracoid,    587 


INDEX. 


I  I  I 


Dislocations,  subglenoid,    597 
symptoms,  575 
treatment,  578 
unreduced,  574 
Diverticula    attached    to    fundus    of 
bladder,  883 
fecal  fistula  from  perforation,  883 
Meckel's,  of  intestine,  877 
mesentery^  of,  879 
obstruction  by,  872,  876 
operating  for,  88 1 
symptoms  of,  without  fecal  ob- 
struction, 880 
oversized,  882 
strangulation  bj-,  802 
Diverticulum  ilei,  87 8 
DoUinger's  bone  ligation.  534 
Douche  spoon,  1030 
Downward   dislocation   of   shoulder- 
joint,  597 
Doyen's  amputation  of  appendix,  731 

vasotribe.  88 
Drainage,  214 

after    operation     for     peritonitis, 

687 
aspiration,  654 
capillary,  217 
in  empyema,  659 
of  abdominal  cavitj",  687 
of  fractures,  566 
of  suppurating  joints,  614,  629 
suprapubic,  628 
tubular,  215 
through,  216 
Drainage-tubes,  215 

intestinal  fistula  from,  ion 
removal,  216 
Dressing  material,  antiseptic,  180 
aseptic,  180 
cotton,  182 
gauze,  182 

hygroscopic  capacity  of,  181 
in  emergency  work,  183 
sterilization,    182 
Dry  gangrene,  1064 
Dugas'  test,  592 

Dumreicher's     distraction     method, 
603 
wedge  cushion,  376 
Duodenojejunal  fossa,  hernia   of,  884 
Duodenum,  myoma  of,  962 

occlusion  of,  in  new-born  child,  927 
perforating  ulcer  of,  694 
Dupuytren's    enterotome,    10 16 
Dynamic    obstruction    of   intestines, 
975 


EcHiNOCOCCUS  cysts,  fractures  and, 

Ecraseur.  89 
Ectopcritonitis,  663,  672 

tissues  in,   676 

treatment,  676 
Edema  in  strangulated  hernia,  984        j 
Elastic  catheters,  635  I 


Elastic    constriction,    64.      See    also 

Constriction. 
Elbow-joint,  disarticulation  at,  1085 

dislocation  of,  599.    See  also  Fore- 
arm, both  bones  of. 
classification,  600 
diagnosis,    600 

drainage   of,   631 

resection  of,    1036 

for   tuberculosis,    1036 
Electricity  for  hemorrhage,  133 

in  intestinal  obstruction,   758 
Elevation  in  prophylaxis,  63 
Embolism  after  fracture,  396 

air,   92 

fat,  after  fracture,  398 
fractures  and,  347 
with  compound  fractures,  515 
Emergency    operations    on    air-pas- 
sages, 640 

surgery,   17 

anesthesia  in,  43 
dressing  material  in,   183 
elastic  constriction  in,  77 
importance  of,  18 
Empyema,   651 

after-treatment,    661 

bacteriology  of,   651 

diagnosis,  653 

dressing  after  operation   for,  660 

etiology-,  651 

incision  of  chest-wall  for,  656 

irrigation  in,  659 

necessitatis,    654 

operation  for.  655 

puncture  in,  623 

rib  resection  in,  656,  657 

Schede's  thoracoplasty  for,  661 

surgical    treatment,    654 

symptoms,   653 

tubular  drainage  in,  659 
Enchondroma,  fractures  and,  318 
Endoperitonitis,  664 
End-to-end  anastomosis,  819 
Enterectomy,  amount  to  be  resected, 
800 

clamps  in,  800 

for  fistula,   10 1 9 

for  gangrene,  799 

for  obstruction,  797 
mortality,  797 

for  removal  of  tumor,  798 

for     sarcomatous     intestinal     ob- 
struction,   969 

for  tuberculosis,  947 

in  infants,  1)29 

in  perforation   of  intestine,   283 

in   volvulus,   865 

Madelung's,  799 

marasmus  after,  792,  802 

partial,  on  concave  side,  802 

restoration    after,    with    unco'Te- 
s[)on(ling  hnnina,  798 

ru1>ber  tube  after,  798 

transplantation  in,  790 
Enteritis,  obstruction  from,  977 


1 1 14 


INDEX, 


Entero-anastomosis     for    tuberculo- 
sis, 953 
Enterolithiasis,  914 

high,  916 

perforation  in,  916 

seat   of   obstruction,   915 

ulceration  and,  915 
Enteroliths,    920 
Enteroplasty  for  tuberculosis,  946 

Heineke-Mikulicz    raethod,    946 

Pean's,  946 
Enterorrhaphy,    808 

circular,  808,  809,  819 
in  obstruction,   786 
Maunsell's,  824 
Murphy  button  as  substitute  for, 

826 
suturing  in,  816 

history,  810 

inflatable  bulb  in,  816 

insertion  of  suture,  813 

lateral,   808,   818  _ 

omental  grafting  in,  821 

serous  surfaces  in,  810 
Enterostomy,   761 

anesthesia  in,  762 

for    intussusception,    901 

for  volvulus,  864 

right  iliac,   761,   762 
inguinal,  763 
Enterotomy,   764 
Enucleation,  subserous,  in  relapsing 

appendicitis,  736 
Epiphyseolysis  and  epiphysitis,   314 

syphilis  and,  319 

traumatic,  325 
Epiphysitis  and  epiphyseolysis,   314 
Epiploitis,  664 

Epityphlitis,   705.      See  also  Appen- 
dicitis. 
Erasion,   1026 
Ergot  as  hemostatic,  135 
Esmarch's     bracketed     wrist  -  joint 
splint,   1036 

chloroform  bottle,  46 
inhaler,   46 

constrictor,  65,  66,  69 

double  inclined  plane,  377 

first-aid  package,  234 

pelvic  supports,  462 

splint,  380 

suspension    splint    for    ankle-joint 
resection,  1048 

tongue   forceps,    52 
Ether,  administration  of,  57 

anesthesia,  42,  56 

disadvantages  of,  56 

inhaler,    5  7 

sulphuric,  as  anesthetic,  58 
Etheridge's  hemostatic  forceps,    112 
Ethyl  chlorid  as  anesthetic,  59 
Eucain,  61 
Evacuation  of  distended  intestines, 

780 
Eventration,  780 

in  peritonitis,  683 


Exarticulation   of    upper  extremity 
with  scapula  and  clavicle,   1088 

Exclusion,    complete,    for    tubercu- 
losis, 960 
partial,  for  tuberculosis,  953 

Exploratory  puncture,  614,  617 
syringe,   618 

Extension  and  counterextension,  595 

Extracapsular  fractures.      See  Frac- 
tures. 


False  joint  at  seat  of  fracture,  564 
Faraboeuf's     bone-cutting     forceps, 

1028 
Fascia,  deep,  suturing  of,  208 
Fecal   concretion,    appendicitis   and, 
711 
extravasation    in    obstruction    by 

bands,  876 
fistula,    761 

from    perforation    of   diverticu- 
lum, 883 
obstruction,  924 
Feces,   examination   of,   in   tubercu- 
losis, 941 
Femoral    hernia,    radical    operation 

for,   1003 
Femur,  fracture  of,  crepitus  in,  443 
inclined  plane  for,  373 
treatment,  373 
neck    of,    fractures    of,    421.      See 
also    Fractures,    extra-    and 
intracapsular. 
after-treatment,  472 
bony  union,  357,  413 
causes,  432-434 
classification,  420 
deformity  in,  436 
diagnosis,  441 
dislocation  and,  599 
eversion  in,  437,  442,  444 
fascia  lata  in,  440 
fixation,  471 

fragments  in  repair  of,  357 
greater  trochanter  in,  444 
impacted,  420,  425 

treatment,  461,  462 
incomplete,  423 
incuneated,  425 
intracapsular,     bony      union 

after,  418 
loss  of  function  in,  435 
measurements  in,  443 
motion  in,  440 

nails  in  treatment  of,  468-470 
nonimpacted,    420 

treatment,  463 
pain  in,  434 
plaster-of- Paris  bandages  for, 

462 
rabbeting  in,  431,  466 
reduction,   471 
Senn's  treatment,  471 
shortening  in,  438,  442 
suggillation  in,  436 


INDEX. 


I  I  I 


Femur,  neck  of,  fractures  of,  swell- 
ing in,  436 
symptoms.  434-441 
time  required  for  union,  461 
treatment,  412.  461 
trochanter  major  in.  440 
shaft  of, fractures  of.  treatment.  544 
Fergussons     bone-cutting     forceps, 

1028 
Ferripyrin  as  styptic,  133 
Fetal  peritonitis,  667 
Fibromata,     intestinal     obstruction 

from,  961 
Field-hospital,    surgeons    work    at, 

254 
Finger-joints,  resection  of,  1034 
Fingers,  amputation  of,   1069,   1082, 
10S3 
elastic  constriction  of,  66 
First-aid  dressing,  application  of.  239 
fixation,  238 
immobilization  in.  242 
package,  Bedoins,  233 
behind  fighting-line,  233 
English,  235 
French.  234 
German,  234 
in  miHtan.-  surger\\  231 
in  Spanish- American  war,  235 
iodoform  gauze  in.  234 
means  of  carrying,  236 
requirements  of,   236 
Senn's.  238 
splints  in.  243 
Fissure.  320 

Fistula,  fecal,   761.      See  also  Enter- 
ostomy. 
intestinal,    1004.      See   also   Intes- 
tinal fistula. 
Fixation  dressings,  213.  543 

embarrassed  circulation  in.  551 
with  bone  ferrule,  540 
Flap  formation  for  gangrene,  1072 
incisions    for    disarticulation    and 
amputation  of  arm.  1087 
Flexion  as  hemostatic  on  field,  246 
intestinal.    866 

exhibition  of  symptoms.  867 
prophylaxis  for  recurrence.  869 
treatment,  869 
Fluhrer's  probe,  222 
Foramen  of  Winslow.  hernia  of,  884 
Forceps,  anastomosis,  Laplace's,  79 1 , 

820 
Forcipressure,  128 

on  field,  249 
Forearm,  amputation  of.  1085 
both  bones  of.  dislocation  of,  600 
anterior,  606 
diverging.  609 
forward.  605 
hyperextension  for,  604 
posterior,  600—603 
fracture  of  both  bones  of.  374 
lateral  luxations  of,  606 
one  bone  of,  dislocation  of,  609 


Foreign     bodies,     intestinal     fistula 

from.  1007 
Formaldehyd  as  antiseptic,  192 
Formalin  as  antiseptic,  192 
for  sterilization  of  catgut,  108 

of  sponges.  17S 
Formic  aldehyd  as  antiseptic,  192 
Fracture  box.  376 
Fractures,  309 

akidopeirasty  in.  341 
ambulator}-  treatment,  545 
ank>iosis  after,  394 
atrophy  after,  396 
autotransplantation  in.  529 
bone  transplantation  for,  408,  409 
bony  vmion  after,  418 
time  for,  417 

vaUdity  of  specimens.  451 
bracketed  sphnts  in.  553 
callus   formation,    defective,    390, 
392 
,  excessive.  390 

painful,  400 

production  after,  351 
causes,  326 

central  ner%-ous  system  in,  399 
circular  plastic  splint  for.  550,  552 
closed,   322 
CoUes',  475 

diagnosis,    477,  484 

impacted,  482 

Moore's  dressing  for,  479,  480 

prognosis,  484 

reduction.  478,  485 

symptoms.  482 

treatment,  478 
comminuted,  326 
comparison  in,  341 
complicated.  326 
compound.  325,  505 

after-treatment,  525 

amputation  for,  519 

callus  formation  in.  561 

counteropenings.  524 

definition.  506 

diagnosis.  513 

drainage,   524.  525,  566 

dressing  of  wound,  523,  525 

etiolog>',  51 1 

fat  embolism  with.  515 

ferment  intoxication  with,  517 

fixation,   direct,   silver  wire   in, 

531 

dressmg,  543 

of  fragments,  direct,  527 
infection  of  wound  in,  515 
inflammator>' swelling  after.  516 
irrigation.  527 

operative  interference,  558,  567 
patholog>-,  514 
prM;.'iiosis,   517 
fjiair,   ;6i 
statistics,  old,  507 

recent,  508 
suppuration  in.  560 
surgeon's  duty,  563 


II  i6 


INDEX. 


Fractures,      compound,       thrombo- 
phlebitis in,  517 

treatment,  519 
ambulatory,  545 
modem,  522 
of  lacerated  wounds,  523 
of  wotmds,  520,  522 
compression,  of  long  bone,  330 
crepitation  and,  342 
decubitus  and,  399 
deformity  in,  335 
delayed  union,  400 
delirium  traumaticum  and,  399 

tremens  and,  399 
dentate,  322,  324 
diagnosis,  332 

differential,  332 
direct,  329 

fixation,  388 
dislocation  and,  575 
displacements  in,  335 

angular,  337 

lateral,  337 

longitudinal,  339 

rotary,  338 
dorsal  recumbency  in,  399 
double  inclined  plane  for,  373,  376 
drainage  in,  566 
during  reduction,  585 
embolism  after,  396 

fat,  398 
emphysema  and,  351 
examination  in,  367 
external  violence  and,  328 
extracapsular,    bony   union   after, 

446-450 
extracervical,  421 
false  joint  at  seat  of,  564 
fat  embolism  and,  347 

urine  in,  349 
fate  of  foreign  material  in,  539 
fever  after,  344 
fibrinous  union  after,  400 
first  duties  of  surgeon,  366 
fixation  by  bone  ferrule,  540 

by  ivory  clamps,  536 
cylinders,  536 

by  nails,  screws,  etc.,  535 

by  Senn's  splint,  538 

dressing,  543 

embarrassed     circulation     in, 

551. 
fragments  m  repair  of,  351 
frequency,  310 
from  bullets.  X-ray  in,  225 
gangrene  after,  397 
Graves'  treatment,  403 
greenstick,  320 
gunshot,  amputation  for,  558 

debridement  in,  554 

in  Greece  and  Turkey,  557 

of  joints,  556 

of  leg,_S56 

resection  for,  558 

treatment,  554 
hemorrhage  in,  398 


Fractures,  hemorrhagic  infarcts  and, 

349 
hereditary  predisposition  to,   319, 

327   .  . 
imm.obilization,  371 

by  bone-nails,  468 

position,  372 
impaction  in,  339 
inclined  plane  for,  386 
incomplete,  320 
indirect,  329 
intra-articular,  325 
intracapsular    and    extracapsular, 
relative  number,  421 

bony  union  after,  452,  456 

diagnosis,  445 

nonunion  after,  454 
intracervical,  421 
ivory  pegs  for,  407,  417 
longitudinal,  323 
loss  of  function  with,  333 
Malgaigne  hooks  in,  388 

and  spear  in,  388 
mensuration  in,  339 
multiple,  325 

muscular  contraction  and,  331 
new  point  of  motion  in,  342 
oblique,   323 
of  femur.      See  Femur. 
of  limbs  on  field,  immobilization, 

253 
of  patella.      See  Patella. 
of    skull,     486.      See     also    Skull. 
osteomyelitis  and,  347,  565 
overriding  in,  339 
pain  and,  334,  345 
paralysis  and,  400 
pathologic,  311 

bone  atrophy  and,  312 

carcinoma  and,  317 

causes,  312 

cysts  and,  318 

diagnosis,  319 

eccentric  anostosis  and,  313 

echinococcus  cysts  and,  318 

enchondroma  and,  318 

of  epiphysis,  314 

osteomalacia  and,  316 

osteomyelitis  and,  313-315 

osteoporosis  and,  312 

rachitis  and,  315 

sarcoma  and,  316 

scorbutus  and,  319 

syphilis  and,  318 

treatment,  320 
permanent  extension  for,  386 
plaster-of-Paris  splint  for,  546 
position  after  reduction,  372 
preternatural  mobility  in,  341 
pseudarthrosis  and,  400 
pseudo-,  310.      See  also  Fractures, 

pathologic. 
reduction,  368 
reraote  consequences,  389 
repair  of,  351,  355 

marrow  in,  355 


INDEX. 


II  17 


Fractures,  repair,  time  for,  404 
reposition,  36S 
restoration  of  continuit)*,  357 
rupture  of  ner^-e-trunks  with,  346 
shock  after,  344 
silver- forked,  477 
sUding  foot -board  for,  387 
special,  411 
splints  for,  Agnew's,  373 

Esmarch's,  380 

Gooch's,  380 

making  of,  380 

mantle,  375 

pasteboard,  383 

plaster-of- Paris,  384 

plastic,  384 

Raoult-Deslongchamp's,  383 

ready-made,  378 

straw,  376 

suspension,  377 

temporar}-,  381 

tin,  383 

wire,  383 
spontaneous,  311 
stiffness  after,  394 
stimulating  repair  in,  564 
subcutaneous  simple,  322 
complications,  346 
direct  fixation  for,  388 
prognosis,  362 
suppuration  and,  346 
symptoms,  332 

following,  344 

local,  345 

objective,  334 

subjective,  333 
temporary-  dressing,  375 
tenderness  with,  334 
thrombophleV>itis  and,  566 
thrombosis  after,  396 
torsion,  330 

transportation  of  patient,  367 
transverse,  322 
treatment,  365 
T-shaped,  323,  324 
ununited,  apparatus  for,  406,  407 
vicious  union  of,  410 
vivifying  ends  in,  564 
X-ray  in,  343 
Y-shaped,  324 
Fragments  of  bone,  fate  of,  539 
Frank's  decalcified  bone  coupler,  826 

intestinal  needles,  798 
French  soft-rubber  catheter,  633 
Fricke's  hemostatic  forceps,  112 


Galbraitm's  leg  amputation,  1098 
Gall-stone,      intestinal      obstruction 

from.  914 
Galvanocautery,  88 
Gangrene  after  fracture,  397 

amrmtation  for,  1062,  1063 
flap  ff>rmation,  1072 

circumscribed,  of  intestine,  799 

dry,  1064 


Gangrene,  dry,  toe  amputation  and, 
1090 

from  gunshot  wounds,  559 

in  strangulated  hernia,  9S5 

moist,  1064 

of  intestine,  in  hernia,  873,  996 
Gangrenous  appendicitis,  719 
Gastric  ulcer,  perforating,  693 
Gastro-enterostomy,  Murphy  button 

in,  789 
Gauze  drainage  of  abdominal  cavity, 
689 

retractors,   107 i 
German  plaster  bandage  shears,  552 
Glass  drains,  215 

Glycerin  as  vehicle  for  iodoform,  199 
Gonococci  in  leukocytes,  158 
Gonococcus  peritonitis,  671 
Gonorrheal  synovitis,  tapping  in,  626 
Gooch's  splint,  380 
Gouges,  1029 

Gouley's  leg  amputation,  1098 
Grafting,    omental,    821.      See    also 

Omental  grafting. 
Graves'  treatment  of  fractures,  403 
Greco-Turkish  war,  fractures  in,  557 
Gritti-Stokes'  amputation,  iioi 
Grooved  directors,  994 
Gunshot  fractures.      See  Fractures. 

wounds,      152,      218.        See      also 
Wounds,  gunshot. 
Giinthcr's  modification  of  Pirogoff's 

amputation,  1095 


Halsted's  mattress  suture,  815,  821 

modification    of    Bassini's    opera- 
tion, 1 00 1 

straight  artery  forceps,  1 1 2 
Hamilton's  bone  drills  with  guard, 

406 
Hand,  amputation  of,  1084 

disinfection,  169 

Kiimmel's  method,  171 
turpentine  in,  172 
Hart's  sponge  holder,  180 
Head,  elastic  constriction  of,  81 
Heart,  gunshot  wounds  of,  262 
Heineke-Mikulicz   enteroplasty,    946 
Heister's  gag,  51 
Hemarthrosis,  tapping  in,  625 
Hematocele,    retro-uterine,    668 
Hemophilia,  hemorrhage  with,  treat- 
ment,  136 
Hemorrhage,  90 

actual  cautery  for,  i  28 

acupressure  for,  131 

air  embolism  and,  92 

angiotripsy  for,  89 

antipyrin  for,  134 

arterial,  91 

invagination  for,  126 

aseptic  ligature  in,  97 

autotransfusion  after,  136 

capillary,  93 

classification,  91 


Iii8 


INDEX. 


Hemorrhage,  cold  for,  131 
diagnosis,  95 

digital  compression  for,  84 
ecrasetir  for,  89 
elastic  constriction  for,  64 
electricity  for,  133 
elevation  for,  63 
ergot  for,  135 
ferrip3'rin  for,  133 
forcipressure  for,  128 
from  bone,  134 

from  chest  wounds  in  war,  271 
from     middle    meningeal     arter)'', 

502 
galvanocauter}^  for,  88 
hot  water  for,  129 
in  abdominal  section,  777 
in  fracture,  398 
in   gunshot  wounds   of   abdomen, 

280 
in  hemophilic  patients,  treatment, 

in   hip-joint   amputations,    elastic 
constriction  for,  73 

intra-abdominal  obstruction   and, 
804 

ligation  for,  85-87 
lateral,  122 

manual  compression  in,  82 

oil  of  turpentine  for,  133,  135 

on  field,   244.      See   also   ^^'oujids, 
gunshot. 

prevention  of,  62 

saline  infusion  in.  13S 

Spanish  windlass  for.  89 

spontaneous  arrest  of,  94 

steam  for,  130 

st^'pticin  for,  136 

styptics  for,  133 

suture  of  vessel  for.  124-126 

symptoms,  95 

tamponade  for,  131 

thermocauter}-  for,  88 

torsion  for,  127 

transfusion  and.  137 

treatment,  96 
general,  134 

venous,  92 

vessel  suttire  for,  122 

wound  suture  for,  132 
Hemorrhagic  peritonitis.  668 
Hemostasis  after  amputation.    1077 

in  arm  amputation.  1086 

permanent,  on  field,  249 

prophylactic,  62 

elastic  constriction  in.  64 
elevation  in,  63 
Hemostatic  forceps,  iii.  112 
Hemothorax,  ptmcture  for.  622 
Hemp  plaster-of-Paris  sphnt,   548 
Henrotin's  gag,  51 

Heppe's  odor  test  for  chloroform,  44 
Hernia,  diaphragmatic,  885 

femoral,     radical     operation     for, 
1003 

incarcerated,  983 


Hernia,    incarcerated,  and    strangu- 
lated,    differentiation,  988 
inflamed  and  strangulated,  differ- 
entiation, 988 
inguinal,  radical  operation  for,  999 
internal,  883 
knives,  993 

of  duodenojejunal  fossa,  884 
of  foramen  of  Winslow,  884 
strangulated,  983 

anesthesia  in,  991 

cold  as  aid  in  reduction,  990  . 

constipation  in,  986 

diagnosis.  985 
differential,  987 

edema  of  loop,  984 

etiolog}-,  983 

examination  of  contents,  996 

gangrene  in,  985,  996 

hemiotom}'  for,  992 

laparotomy"  for,  772 

other  organs  in  sac,  998 

pain  in.  986 

prognosis,  988 

radical  operation  for,  998 

reduction  of,  after  herniotomy, 
991 

reheving  constriction,  995 

stricture  following,  942 

sj^mptoms,  985 

taxis  in,  continuance  of,  991 

treatment,  989 
medical,  989 

vitality  of  bowel  in,  996 

vomiting  in.  986 
tuberciilosis  of.  934 
umbilical, radical  operation  for,  998 
Hernial  sac,  stripping  of,  999 

suture  of.  1000 
Hemiotom}',  992 

circulation  after.  996 
exposing  field  for,  992 
incisions  for,  992 

peritoneum  in,  994 
indications  for.  992 
obstruction  and  peritonitis  after, 

979 
opium  after,  979 
reduction  after,  996 
removal  of  adhesions,  995 
Hip-joint,  amputation  of,  bloodless, 

73 
Senn's,  77 
dislocations  of,  598 
drainage  of,  631 
elastic  constriction  at,  73 
resection  of,  1032,  1056 
for  tuberciolosis,  1056 
incisions  for,  1057 
indications,  1056 
with  temporar}^  resection  of  tro- 
chanter, 1057 
Hodgen's  suspension  splint,  379 
Hofmeister's  sterilization  of  catgut, 
108 
Senn's  modification,  109 


INDEX. 


I  I  19 


Hopkins'   rongeur   forceps  as   modi- 
fied by  Weir,  500 
Horsehair,  preparation  of,  113 

suture  for  intestine,  813 
Houze's  tongue  forceps,  52 
Humerus,  fractures  of,  oblique,  treat- 
ment, 545 
splint  for,  382 
subcoracoid  dislocation  of,  590 
Husson's  sponge  holder,  50 
Hutchinson's  abdominal  taxis,  857 
Hydrocele,  tapping  of ,  629 
Hydrocephalus,  puncture  in,  621 
Hydrogen  insutllation  in  abdominal 
wounds,  277 
in  intussusception,  899 
in  invagination,  889 
of  bowel,  751 
peroxid  as  antiseptic,  194 
Hydrophobia  antitoxin,  186 
Hydrothorax,   circumscribed,   punc- 
ture in. 623 
Hypodermic  needles,  614 

preparations,  sterility  of,  616 
syringe,  614 


Ice  and  salt  anesthesia,  539 
Ileocecal   abscess,   tuberculosis  and, 

939 
opening,  congenital  stenosis  of,  925 
valve,  competency  of,  748,  751 
Ileocolostomy,  785,  786,  833 
by  implantation,  834 
by  lateral  apposition,  835 
by  perforated  discs,  837 
Maunsell's,  839 
shock  after,  837 
Ileo-ileostomy  by  bone-plates,  833 

by  perforated  discs,  831 
Ileorectostomy.  839 
Ileosigmoidostomy,  789 
Ileum,  myoma  of.  962 
tuberculosis  of,  951 
Ileus,    737.      See   also   Intestinal   ob- 
struction. 
Iliac    arteries,    transperitoneal    liga- 
tion of.  86 
Immobilization  in  first  aid.  242 
of  fractured  limbs  on  field,  253 
of  joints  on  field,  253 
Impaction,  425 

by  foreign  bodies,  9  r  2 

disintegration  of  stone,  919 
high,  916 
treatment.  918 
Implantation  of  bone.  1050 
after  necrosis.  105  i 
asepsis  at  seat  of.  J051 
bv  hV>^>dU'Ss  method.  1052 
iV       '  ■].  1050 

1053 
i\i'     i:..    /i  wmnA.  1053 
indicatirms  for.   105 1 
method.  1050 
secondary,  1053 


Implantation  of  bone,   suppuration 
after,  1053 
technic,  1052 

treatment    of   external    wound, 
1052 
Incarcerated  hernia,  983 
Infarcts,   hemorrhagic,   in   fractures, 

349 
Infection  from  puncture,  615 
Inflatable  bulb,  Reder's,  816 
Inflated    bulbs   in    circular    enteror- 

rhaphy,  820 
Infraction,  320 

Inguinal  canal,  closing  of,  1000 
incision  to  expose,  992 

hernia,  radical  operation  for,  999 
Instruments,   sterilization  of,  174 
Insufflation   in   intussusception,   899 

in  search  for  perforations,  282 

of  hydrogen  in  invagination,  889 

rectal,  751 

test  for  permeability  of  intestines, 

I  783 

I  Internal  hernia,  883 

I  Intestinal  anastomosis,  783 

!  by  suturing,  790-792 

complete   physiologic   exclusion 

by,  796 
for  fistula,  10 18 
for  intussusception,  905 
in  congenital  atresia,  789 
in  volvulus,  861 
indications,  792 
lateral  implantation  and,  826 

plates  for,  828 
Murphy  button  in,  789 
partial  physiologic  exclusion  h»y, 

792 
plates  for,  784 

approximation,  784 
bone,  786 
suturing  in,  790 
time  required  for,  791 
clamps,  800 
concretions,  920 

fistula,    761,    1004.      See   also   En- 
terostomy. 
anastomosis  for,  10 18 
cauterization  for,  1014 
drainageofabscesscavityin,  1023 
enterectomy  for,  10 19 
etiology,  1005 
forms,  10 1  2 
from  abdominal  aV>scc.ss,  1008 

operation,  1009 
from  abscess,  1 006 
from  actinomycosis,   1008 
from  appendicitis,  1008 
from  carcinoma,  1007 
from  drainage-tubes,  loii 
from  foreign  lK)dies,  1007 
from  gunshrit  wounds,   1005 
from  ligatures,   10 10 
from  nialii,'n.inl  tumors,  1007 
from  pelvic  at)s<ess,  1008 
operation,  1009 


II20 


INDEX. 


Intestinal  fistula  from  stab  wounds, 
1005 

from  strangulation,  1007 

from  submural  injury,  1005 

from  sutures,  10 10 

from  ulceration,  1006 

in  appendicitis,  734 

pathologic  anatomy,  1012 

plastic  operation  for,  10 17 

prophylaxis     against    infection, 
1020 

removal  of  spur  in,  10 16 

repression  of  spur  in,  1015 

spontaneous  closure,  10 12 

suturing     of,     without    opening 
peritoneum,  1017 

treatment,  loii 
surgical,  10 14 
loop,   anchoring  of,  in  colostomy, 

766 
needles,  798,  813 
obstruction,  737 

abdominal  section  for,  770 
taxis  for,  857 

acute,  739 

colicky  pains  in,  740 
constipation  in,  739 
intestinal  coils  in,  744 
symptoms,  742 
tympanites  in,  740 
vomiting  in,  740 

after  abdominal  section,  980 

after  diarrhea,  9S0 

after  herniotomy,  979 

after  laparotomy,  870 

after  ovariotomy,  805,  870 

after-treatment,  807 

alimentation  in,  745 

anastomosis  and  lateral  implan- 
tation in,  826 

anastomosis  for,  783 

anatomicopathologic  forms,  847 

and  peritonitis,    differentiation, 
741 
evacuation  in,  781 

appendix  and,  876 

ascites  in,  741 

bowels  after,  807 

b}'  adhesion,  802 

by  band,  802,  872 

fecal  extravasation  in,  876 
location  of,  875 
operating  for,  875 

by  cicatricial  stenosis,  868 

by  circumscribed  parietal  adhe- 
sions, 804 

by  concretions,  920 

by  contraction  where  diverticu- 
lum is  given  off,  881 

by  diverticula,  802,  872,  876 
operating  for,  881 

by  enteroliths,  921 

by  flexion,  802 

b}^  foreign  bodies,  912 

by  margins  of  opening  in  mesen- 
tery or  omentum,  874 


Intestinal    obstruction   by   Meckel's 
diverticulum,  87 7 

by  pelvic  adhesions,  804 

by  stenosis,  925 

by  twisted  coils,  792 

by  visceral  adhesions,  804 

cathartics  and,  748,  807 

chronic,  743 

diarrhea  in,  744 
intestinal  coils  in,  744 
s^^mptoms,  743 

classification,  847 

colorectostomjr  for,  840 

colostomy  for,  765 

colotomy  for,  7  64 

definition,  738 

distention  in,  740 

of  colon  with  fluids  in,  748 

dj'namic,  738,  848,  975 

effects    of    contents    above    ob- 
struction, 746 

electricity  in,  758 

enterectomy  for,  797 

enterospasm  and,  849 

enterotomy  for,  761,  764 

evacuation  in,  780 

eventration  for,  780 

examination  for  hernia  in,  986 

fecal,  924 

following  contusion,  978 

frequenc}^  737 

from  adhesions,  866,  870 

due  to  peritoneal  defects,  805 

from  atresia.  925 

from  band  constriction,  849 

from  benign  tumors,  961 
diagnosis,  968 

from  blood  clot,  804 

from  calculus,  954 

from  carcinoma,  970 

froin  compression,  974 

from  cysts,  967 

from  enteritis,  977 

from  fibromata,  961 

from  flexion,  866 

from  gall-stones,  914 

from   healed   tubercular   ulcers, 
938 

from  internal  hernia,  symptoms, 

849 

from  ligamentous  bands  in  ab- 
dominal cavity,  873 

from  lipomata,  962 

from  malignant  tumors,  968 
mortality,  972 
treatment,  972 

from  myofibroma  of  the  rectum, 
964 

from  myomata,  962 

from  parasites,  922 

from  polypi,  962 

from  sarcoma,  968 

enterectomy  for,  969 

from  traumatic  paresis,  978 

from  tumors,  961 

from  tympanites,  975 


INDEX. 


I  121 


Intestinal  obstruction  from  volvulus, 

850 
hernia  and,  diagnosis,  987 
ileocolostomy  for,  833 
ileorectostomy  for,  839 
insufflation  in,  750,  751 
intra-abdominal         hemorrhage 

and, 804 
irrigation  of  stomach  in,  747 
jejuno-ileostomy  for,  829 
laparo-enterotomy  for,  797 
laparotomy  for,  758,  770 
lavage  of  stomach  in,  745 
Madelung's  treatment,  779 
manual   exploration   of   rectum 

in.  754. 
massage  in,  755 
mechanical,  738,  848 
not  due  to  intussusception,  site 

for  incision,  879 
paralysis  and,  849 
peritonitis  and,  976 
pulse  in,  741 

puncture  of  intestine  in,  756 
rectal  injections  in,  745 
shock  after,  807 
sigmoidostomy  for,  765 
stomach-feeding  in,  745 
stomach-tube  in,  746 
strangulation,  symptoms,  849 
support  of  abdomen  in,  748 
symptoms,  738 
taxis  in,  755 
temperature  in,  741 
thirst  after,  807 
toilet,  806 
treatment,  medical,  744 

operative,  758,  783 
mortality,    759 

when  obstruction  can  not  be 
found,  784 
tubage  in,  754 
typhlostomy  for,  765 
occlusion,  912 

814 


See  also  Enteror- 


re sec ted. 


suture,  double, 

history,   810 
suturing,   808. 
rhaphy. 

material,  813 
wall,  resistance  of,  7^2 
Intestine,    amount    safely 

800 
circumscribed  paresis  of,  975 
contraction  of,  where  diverticulum 

is  given  off,  88 r 
distended,  evacuation  of,  780 

Madelung's    method    of    treat- 
ment. 779 
emptying,  in  volvulus,  860 
examination  of,  loop  by  loop,  778 
gangrene  of,  circumscribed,  799 
large,  typhlostomy  for  oVjstruction 

of,  766 
malignant  stenosis  of,  congenital, 

925 
nonmalignant  stenosis  of,  925 

71 


Intestine,   overdistended,  in   perito- 
nitis, 686 
perforation  of,  enterectomy  for,  283 

suturing  of,  283 
permeability  of,  test  for,  783 
physiologic     exclusion     of,     com- 
plete, 796 
partial,  792 

in  animals,  794 
therapeutic  value,  794 
tissue  changes,  794 
puncture  of,  in  obstruction,  756 
replacing  of,  780 
resection  of,  792 
restoring  continuity  of,  784 
search  for  perforations  of,  282 
small,  submucosa  of,  813 
stricture  of,  congenital,  942 

following    strangulated    hernia, 

942 
following  typhoid  ulcer,  943 
malignant,  944 
syphilitic,  943 
traumatic,  942 
tuberculosis     of,     930.      See     also 

Tuhercnlosis. 
tumor  in  lumen  of,  764 
twisted,  obstruction  by,  792 
wounds  of  concave  side,  enteror- 
rhaphy  for,  808 
healing  of,  816 
Intra-abdominal  examination  in  lap- 
arotomy, 777 
Intracapsular   fractures.      See   Frac- 
tures. 
Intracoracoid  dislocation,  587 
Intra-intestinal    saline   injections   in 

peritonitis,  69  r 
Intralaryngeal  tubercular  affections, 

laryngofissure  for,  644 
Intra-uterine  peritonitis,  667 
Intubation  of  larynx,  640 
dangers  of,  643 
diet  after,  643 
Intusstisccption,  885 
acute,  893 

adhesions  in,  895 
circulation  in,  895 
gangrene  in,  895 
irreducibility,   895 
pathology,  894 
sloughing  in,  895 

postmortem  description,  895 
spontaneous  cure,   895 
adhesif)ns  in,  905 
age  and,  890 
air-insu Illation  in,  899 
anastomosis  for,  905 
ascending,  888 
blood  in  feces  in,  894 
chronic,   893 

adhesions  in,  895,  89 7 
hvi)erj)lastic  changes  in,  S97 
rjf  colon,  with  carcinoma,  901 
patholr)gy,  897 
sloughing  in,  897 


II22 


INDEX. 


Intussusception,      chronic,      tumors 
and,  897 
colostomy  for,  900 
constriction  of  intussusceptum  in, 

895 

descending,  888 

diagnosis,  893 

disinvagination,  904 

distention  of  colon  in,  888 

double,  893 

early  recognition,  898 

enterostomy  for,  901 

etiology,  889 

extra-abdominal  treatment  of  in- 
tussusceptum, 907 

gangrene  and,  808,  907 

hydrogen  insufflation  in,  889,  899 

ileocecal,  888,  893 

intestinal    contractions   in,    quiet- 
ing, 898 

into  walls  of  rectum,  890 

laparotomy  for,  901 
age  and,  903 
incision,  904 
mortality,  902 

lateral  implantation  in,  908 

massage  in,  900 

mechanism,  890 

mortality,  890 

of  colon,  888 

perforation   of  intussuscipiens  in, 
888 

prognosis,  898 

rectal  insufQation  in,  899 

recurrence,  905 

reduction,  888,  898 
anesthesia  in,  889 

resection    of   intussusceptum    for, 

905.  909 
through  rectum,  911 
rupture  in,  900 
Senn's  taxis  for,  904 
spontaneous  cure,  902 
subacute,  893 
swelling  in,  894 
symptoms,  893 
taxis  for,  904 
tenesmus  in,  894 
total  resection  for,  907 
treatment,  898 
tumor  and,  891 

resection  for,  892 
ultra  acute,  S93 
Invagination,    885.      See   also  Intus- 
susception. 
arterial,  126 
by  rubber  ring,  846 
suture,  841 
material,  845 
Nothnagel's  test  in,  844 
symptoms,  849 

with  intestinal  tuberculosis,  959 
lodin  as  antiseptic,  194 
Iodoform,  194 
as  first  aid,  234 
gauze,  195 


Iodoform  glycerin  after  tapping  oi 
joints,  626,  627 
as  vehicle  for,  199 
intoxication,    195 
from  drainage,  689 
Irrigation,     antiseptic,     permanent, 

565         . 
in  peritonitis,  684,  692 
of  abdominal  cavity,  283 
Ivory  clamps,  536 
cylinders,  536 
nails,  etc.,  fate  of,  539 

use  of,  468 
pegs  for  delayed  union,  407 

for  fracture,  417 


Jejuno-ileostomy,  829 
by  bone-plates,  833 
by  perforated  discs,  831 
by  suturing,  830 
Jejunum,  obstruction  of,  764 
Jobert's  invagination   suture,  Senn's 

modification,  841 
Johnston's  method  of  sterilizing  cat- 
gut, no 
Jointed   male   and   female    catheter, 

636 
Joints,  ankylosis  of,  394 

dislocations  of,  irreducible,   resec- 
tion for,  1026 
fixation  of,  resection  for,  1026 
gunshot  injuries  of,  556 

wounds  of,  treatment,  1024 
resection  of,  1024 
atrophy  and,  1032 
atypical,  1026 
detachment  of  capsule  in,  1031 

of  peritoneum  in,  1031 
elastic  constriction  in,  1032 
for  disease,  1026 
general  directions,  1030 
immobilization  after,  1032,  1033 
incisions  for,  1030 
indications,  1025 
instruments  for,  1029,  1030 
limits  of,  1025 
of  special  joints,  1033.      See  also 

Finger-joint,  Hip-joint,  etc. 
preservation  of  muscular  attach- 
ments in,  1027 
subperitoneal,  103 1 
success  of,  1033 
technic,  1026 

temporary  resection    of   promi- 
nences in,  1026 
typical,  1026 
stiffness  of,  394 

suppurating,  drainage  of,  614,  629 
tapping  of,  625 
technic,  627 
Juniper  as  antiseptic,  196 


Kappeler's     methods    of   restoring 
respiration  in  anesthesia,  52 


INDEX. 


II23 


Karyokinesis,  153 
Keen's  rongeur  forceps,  499 
Keith's  drain,  217 
Kelly's  intestinal  needles,  798 
Kidney,  gunshot  wounds  of,  291 
laparotomy  for,  295 
nephrectomy  for,  295,  296 
Simon's  incision  of,  296 
treatment,  295 
wounds  of,  291 
Knee,  tuberculosis  of,  resection  for, 

1049 
Knee-joint,  disarticulation  of,  iioi 
drainage  of,  631 
fractures  of,  temporary  plaster-of- 

Paris  splint  for,  548 
resection  of,  1032,  1033,  1048 
drainage  after,  1055 
dressing  for,  1055 
hemostasis  after,  1054 
in  children,  1056 
motion  after,  1056 
typical,  1054 
Knie's  colostomy,  769 
Kochcr's  grooved  director,  994 
hemostatic  forceps,  1 1 1 
method  of  sterilizing  catgut,  1 10 
resection  of  ankle-joint,  1046 

of  wrist-joint,  1034 
rotation  method,  596 
sterilization  of  silk,  106 
Koch's  hypodermic  syringe,  615 
Koenig's  tracheotomy  tube,  648 
Kiimmel's    method    of    disinfecting 
hands,  171 


Langenbeck's  bone  drills,  406 
bone-cutting  forceps,  1028 
first  aid,  234 
incisions  for  elbow-joint  resection, 

1036,  1037 
narrow  saw,  1029 
oval  flap  operation,  1080 
resection  of  ankle-joint,  1045 
of  shoulder-joint.  1044 

Laparo-enterotomy   for  obstruction, 

797 
Laparotomy,  770.     See  also  Abdom- 
inal section. 
for  intestinal  obstruction,  758 
for  intussusception,  901.      Sec  also 

/  ntussusceplion . 
for  yjcrforating  typhoid  ulcer,  695 
for  peritonitis,  680 
in  war,  254 
Laplace's  anastomosis  forceps,   791, 

820 
Laryngofissurc,  643 
Larynx,  incision  of,  anterior  median, 
''MS 
intubation  of,  640 
dangers  of,  643 
diet  after,  643 
stenosis  of,  intubation  ior,  640 
La  stupcur  locale,  29 


Lateral  enterorrhaphy,  818 

implantation,     intestinal     anasto- 
mosis and, 826 
ligation,  122 
Lavage  of  stomach  in  intestinal  ob- 
struction, 745 
Le  Fort's  modification  of  Pirogoff's 

amputation,  1095 
Leg,  amputation  of,  1096 

suturing  wound  of,  1099 
fractures,  gunshot,  556 

of  both  bones,  treatment,  544 
Lembert  suture,  813 

inversion  of  margins  in,  815 
tying  of,  815 
uses  of,  815 
Lever  method  of  reduction,  595 
Lewis'   needles   and   syringe   for   in- 
filtration anesthesia,  59 
Lifting-back  metacarjjal  saw,  1029 
Ligation  and  thrombus,  99 
cicatrization  after,  101,  103 
double,  114 
en  masse,  121 
granulation  after.  104 
intermediate,  121 
lateral,  122 

for  hemorrhage  on  field,  250 
of    arteries  in  continuity,  prelim- 
inary, 85 
percutaneous  temporary,  87 
temporary,  86 
of  axillary  artery,  1087 
of  blood-vessel,  adv-antages,  99    , 
of  veins,  percutaneous  temporary, 

87 

on  field,  249 

repair  of  adventitia  after,  603 

sloughing  and,  1 1 5 

transperitoneal,  of  iliac  arteries,  86 
Ligature,  application  of,  113 

aseptic,  97 

carrier,  1 14 

catgut,  106 

double  catgut,  use  of,  119 

intestinal  fistula  from,  loio 

material,    106 
Limbs,  elastic  constriction  of,  66 

duration.  68 
Lime,  chlorinated,   190 
Lipomata,      intestinal      obstruction 

from,  962 
Lisfranc's  tarsometatarsal  disarticu- 
lation, 1092 
Lister's  boric  acid  ointment.  204 

drainage  forceps,  !;67 

splint  for  resection  of  wrist-joint, 

I0.3.S 
Liston's  bone-cutting  forceps,  1028 

oval  flaj)  amputation,  1080 
Little's  hemostatic  forcej)S,  1 1 1 
Lloyd's  hip-joint  constriction,  75 
Lower  extremity,  amputations  of, 

1089 
Lubricant  for  catheter.  638 
Lucckc's  resection  of  hip-joint,  1058 


1 1  24 


INDEX. 


Luer's  hemostatic  forceps,  112 

Lumbar  puncture,  621 

Lumbricoid    worms,    intestinal    ob- 
struction by,  923 

Luxatio  humeri  erecta,  arm  in,  588 

Lymphadenitis    and    hernia,   differ- 
entiation, 988 
from  tuberculosis,  936 

Lysol  as  antiseptic,  196 


Macewen's  chisel,  1029 
gouges,   to29 

manual  compression  of  aorta,  82 
operation    for    inguinal    hernia, 

999 
Madelung's  incision  m  enterectomy, 

799 
method   for   distended   mtestmes, 

779  .    .       .  , 

Magnesium  sulphate  injection   after 

evacuation  of  intestines,  781 
Male  metal  catheter,  635 

urethra,  633 
Malgaigne  hooks  and  spear  in  frac- 
ture, 388 
subastragaloid  disarticulation, 

1094 
Malleoli,  excision  of,  in  Syme's  am- 
putation of  ankle-joint,  1094 
temporary  resection  of,  in  ankle- 
joint  resection,   1047 
Mantle  splint,  375 

Manual   compression   after   amputa- 
tion, 1077 
exploration  of  rectum  in  obstruc- 
tion, 754 
Marasmus  following  resection  of  in- 
testine, 792, 802 
Marmorek's  antistreptococcic  serum 

in  peritonitis,  691 
Marrow,  autotransplantation  of,  361 

in  bone  repair,  355 
Massage  in  intussusception,  900 

in  obstruction,  755 
Mathieu's  bone-holding  forceps,  107 1 
Mattress  suture,  Halsted's,  815,  821 
Maunsell's    circular,    enterorrhaphy, 
824 
ileocolostomy,  839 
resection  of  intussusception,  911 
Maydl's  anchoring  of  intestinal  loop, 
766 
left  inguinal  colostomy,  767 
Mayo's  intestinal  needles,  798 
McBurney's  incision,  683 

muscle-splitting  operation,  726 
point,   721 

reduction  in   shoulder   dislocation 
with  fracture,  598 
Meatus,  disinfection  of,  before  cathe- 
terization, 637,  638 
Meckel's  diverticulum,  877 

obstruction   by,    operating    for, 

881 
strangulation  by,  803 


Medication,  parenchymatous,  614 

subcutaneous,  614 
Mediotarsal  disarticulation,  1092 
Meningeal    artery,    middle,    hemor- 
rhage from,   502 
Meningitis,  puncture  for,  621 
Mercier's      single  -  elbow      prostatic 

catheter,    635       _ 
Mesenteric  glands,  infection  of,  from 
intestinal  tuberculosis,  935 
suture,  Mitchell-Heamner,  816 
Mesenteriolum,  tying  of,  730 
Mesenteritis,  664 

volvulus  from,  851 
Mesentery  of  diverticulum,  879 
shortening  of,  after  volvulus,  862 
strangulation  by  margins  of  open- 
ing in,  874 
Metacarpal  saw,  lifting-back,  1029 
Metal  catheters,  635 
Metatarsophalangeal  joint  of  big  toe, 
resection  of,  1044 
of  toe,  disarticulation  of,  1090 
Metatarsus,      amputation      through, 

1091 
Meteorismus  peritonei,  673 
Microbes,  air  as  carrier,  160 
Middeldorpf's  akidopeirasty,  592 
Mikulicz  drain,  689 

resection         of        intussusceptum 

through  rectum  ,911 
tampon,   132 
Mihtary  spirit  of  army  surgeon,  25 
surgeon,  courage,  26 
duties,  20 
education,  23 
in  war,  27 

mental  qualifications,  23 
military  spirit,  25 
personal  habits,  26 
physical  condition,  22 
punctuality,    25 
qualifications,   20 
surgery,   17 
aseptic,  231 

first-aid  package  in,  231 
Milk,  intestinal  tuberculosis  and,  931 
Mitchell-Heamner  mesenteric  suture, 

816 
Moist  gangrene,  1064 
Moore's  dressing  for  CoUes'  fracture, 

479,  480 
Morris'  capillary  drainage,  690 
Mouse-tooth  forceps,  994 
Murphy  button,  789 

as  substitute  for  circular  enter- 
orrhaphy, 826 
objections  to,  790 
drain,   217 
Muscles,  tearing  of,  amputation  for, 

1061 
Muscular     contraction,      dislocation 

from,  589 
Musculocutaneous  flap,  108 1 
Myofibroma  of  rectum,   obstruction 
from,  964 


INDEX. 


I  125 


Myomata,    -  intestinal      obstruction 
from,  962 


Nails,  ivory,  fate  of,  539 

metallic,  535 
Narcosis.      See  Anesthesia. 
Neck,  anatomy  of,  645 

gunshot  wounds  of,  259 
Necrosis,    bone    implantation    after, 

1051 
Needle-holders,  211 
Needles,  210 

intestinal,  79S,  S13 
Nelaton  probe,  222 
Nerves,  gunshot  wounds  of,  28S 

suture  of,  288 

tearing  of,  amputation  for,  io6i 
Nervous  system,  central,  in  fracture, 

399 
Neuroblasty,  1068 

Neuroma    after    arm     amputations, 
1086 
amputation,    1066 
etiology,  1067,  1068 
excision  of,  1068 
growth  of,  1067 
prophylaxis  for,  1066 
return  of,  1068 
structure  of,  1067 
Neuromatosis,  1068 
New-bom    child,    occlusion    of   duo- 
denum in,  927 
Nothnagel's     test     in     invagination 

suture,  844 
Nurse,   trained,   in   operating  room, 

165 
Nussbaum-Czerny  operation,  999 
Nussbaum's     iodoform     deodorant, 

195 


O'Dwyer's  extractor,  641 

introducer,   641 

intubation  tubes,  640 
Oil  of  turpentine  for  hemorrhage,  133, 

135 
Olecranon  process,  fractures  of,  treat- 
ment, 373 
Olive-tiyj  elastic  web  catheter,  635 
Omental  grafting,  821 

after  hysterectomy,  824 

after  ovariotomy,  824 

in  abdominal  operations,  823 

in  peritoneal  defects,  824 

inflications,  823,  824 
Omentum,  strangulation  by  margins 

of  opening  in,  874 
Oncotomy,  698 
<')ozing,  surface.  93 
<^)pen  method  of  reduction,  584 
Operating  room,  164 

in  private  hou.ses,  167 

moficm,  167 

trained  nurse  in,  165 
Opium  after  herniotomy,  979 


Os  calcis,  posterior  process  of,  frac- 
ture of,  treatment,  374 
Osteomalacia,  fractures  and,  316 
Osteomyelitic    processes,    bone    im- 
plantation for,  105 1 
Osteomyelitis  and  fractures.  565 

fractures  and,  313-315 
Osteophytes  after  amputation,  1076 
Osteoporosis,  fractures  and,  312 
Ovarian  tumor,  tuberculosis  and,  943 
Ovariotomy,  adhesions  after,  870 
intestinal  obstruction  after,  S05 


Papier-mache  catheter  case,  638 
Paracentesis,  614,  620 
abdominis,  624 
pericardii,  621 
Paralysis   after   elastic    constriction, 
70 
amputation  for,  1065 
fracture  and,  400 
of  intestines,  circumscribed,  975 
traumatic,    intestinal    obstruction 
from,  978 
Parasites,       intestinal       obstruction 

from,  922 
Parenchymatous  injection,  617 

medication,  614 
Parietal  peritonitis,  664 
Parker's  capital  saw,  1070 
Pasteboard  splints,  383 
Patella,  Agnew's  splint  for,  373 
fractures  of,   from   muscular  con- 
traction, 331 
Malgaigne  hooks  for,  388 
treatment,  373 
suturing  of,  after  resection,  1054 
Pean's  enteroplasty,  946 
Pelvic    operation,    intestinal    fistula 
from,  1009 
peritonitis,  665,  675 

treatment,  702 
supports,  462 
Pelvis,   abscess  of,   intestinal   fistula 
from,    1008 
fractures  of,  treatment,  374 
Penis,  elastic  constriction  of,  66 
Perforating  gastric  ulcer,  693 
typhoid  ulcer,  695 
ulcer  of  duodenum,  694 
Perforation  of  intestine,  .search  for, 
282 
suturing  of,  283 
Perforative  appendicitis,  718 
Pericardium,  ])uncture  of,  621 
Perineal      section      for     rui)ture     of 

urethra,  306 
Periosteum,     bone-production     and, 

.353. 3.';,'; 
Peritoneal  abscess,  676 
cavity,  drainage  of,  687 

toilet,  806 
fla[)  in  amputation,  1076 
suture,  813 
tuberculosis,  697 


1126 


INDEX, 


Peritoneum,  defects  of,  covering  of, 

805 
effect  of  scarification,  812 
incision  of,  in  herniotomy,  994 
irritation  of,  effect  on  repair,  811 
Peritonitis,  662 

acute  septic,  irrigation  in,  6S5 

tubercular,  697 
adhesiva  seu  sicca,  669,  697 
after  hemiotomj",  979 
anatomic  classification,  663 
and  intestinal  obstruction,  evacua- 
tion in,  7S1 
appendicitis  and,  718 

treatment,  702 
bacillus  coli  communis  and,  671 
bacteriologic  classification,  669 
chronic,  675 
circumscribed,  673,  696 
clinical  classification,  672 
deformans,  669,  69 S 
diaphragmatic.  665 
dift'use  septic,  667,  672 
drainage  in,  687 
drugs  in,  679 

etiologic  classification,  665 
eventration  in,  683 
exudative,  669 
fetal,  667 
fibrinoplastic,  669,  674,  698 

adhesions  in,  699 

incisions  for,  682 
from   lesions   of   female   genitalia, 

702 
from  tuberculosis,  936 
gonococcus,  671 
hematogenous,  674,  700 
hemorrhagic,  668 
idiopathic,  665,  700 
incision  of  overdistended  intestine 

in,  686 
infantum,  667 

intestinal  obstruction  and,  976 
differentiation,  741 

treatment,  977 
intra-intestinal  saline  injections  in, 

691 
intra-uterine,  667 
irrigation  in,  684,  692 
laparotomy  for,  680 
metastatic,  666,  674,  700 
neonatorum,  667 
operation  for.  680 

drainage  after,  687 
parietal,  664 

pathologic  classification,  667 
pelvic,  665,  675 

treatment,  702 
perforation  and,  718 
perforative,  666,  673 

treatment,  692 
pneumococcus,  670 
puerperal,  666,  675,  703 
putrid,  668,  677 
septic,     general,     after-treatment, 

691 


Peritonitis,     septic,     general,     even- 
tration in,  683 
irrigation  in,  684,  692 
operation  for,  680 
history,  681 
incision,  681 
preparations,  6S0 
overdistended     intestine     in, 

686 
serum  treatment,  691 
thirst  in,  691 

toilet  with  sponges  in,  686 
treatment,  677 
medical,  679 
operative,  680 
Marmorek's  serum  in,  691 
treatment,  676 
seropurulent,  668,  698 
serous,  669 
staphylococcus,  670 
streptococcus,  670 
subdiaphragmatic,  675,  704 
suppurative,  668,  697 

treatment,  676 
sj'mptoms,  662 
toilet  with   sponges  in,    686 
traumatic,  665 
treatment,  medical,  679 
tubercular  infection  and,  671 
visceral,  664,  674 
treatment,  701 
with  appendicitis,  714 
Permanganate  of   potash  as   sponge 
sterilizer,  178 
solution,  203 
Peruvian  balsam  as  antiseptic,  196 
Petit 's  circular  amputation,  1075 

fracture  box,  377 
Pever's  patches  in  tuberculosis,  935 
Phlebitis,  thrombosis   after   fracture 

and,  396 
Ph^'siologic    exclusion    of    intestine, 
complete,  796 
partial,  792 

in  animals,  795 
therapeutic  value,  794 
tissue  changes,  794 
Pirogoff's  amputation,  1094 
Plain  trocar,  620 

Plaster-of-Paris  bandage  for  fracture 
of  neck  of  femur,  462 
splints,  384,  546 
fenestrated,  546 
removal,  551 
saw  for,  552 
shears  for,  552 
strips  dressing,  550 
Plastic  operations  as  substitutes  for 
amputation,  1062 
on  hand,  1084 
splints,  384 

circular,  550,  552 
Pleura,  puncture  of,  622 
Pleuritis,   secondary,   with   pneumo- 
nia, 652 
suppurative,  651 


INDEX. 


I  127 


Pleuritis,      suppurative,      diagnosis, 
653 
dust  in  etiolog}-  of,  653 
nontraumatic  primary,  653 
surgical  treatment,  654 
Pneumococcus  peritonitis,  670 
Pneumonia,  croupous,  651 

dust  as  cause  of,  653 

microbes  of,  651 

secondary  pleuritis  with,  652 
Polypi,  intestinal  obstruction  from, 

962 
Porto  Rico,  gunshot  wounds  in,  229 
Port's  tirst  aid,  234 
Posterior  dislocation  of  shoulder,  597 

plaster  splint  for  leg,  549 
Potassium    permanganate    as    anti- 
septic, 197 
Preglenoid  dislocation,  587 
Primary  union,  154 
Probe-pointed  director,  994 
Probes,  221 
Probing,  221,  222 
Prostatic  catheters,  635 
Pseudarthrosis,  400 

bone  transplantation  for,  408,  409 

silver  wire  in,  531 

treatment,  405 
Pseudofracture,  311.      See  also  Frac- 
tures, pathologic. 
Puerperal     pclvioperitonitis,     adhe- 
sions after,  871 

peritonitis,  666,  675,  703 

sepsis,  foudroyant  form,  703 
peritonitis  and,  703 
Punctio  vesicae,  627 
Puncture,    disinfection    of   skin   for, 
617 

explorator>%  614,  617 

for  hydrocephalus,  621 

in  intestinal  oljstruction,  756 

infection  and,  615 

lumbar,  621 

of  pleura,  622 
Pus-microbes,  157 

and  suppuration,  relation,  160 
Putrid  peritonitis,  668 


Rabbeting,  466 

Rachitis  and  fracture,  315 

Radial  flap  disarticulation  of  thumb, 

1083 
Radius,  head  of,  dislocations  of,  610 
backward,  61 1 
downward,  613 
etiology,  6fo 
forward,  61  2 
mechanism,  610 
outwarrl,   612 
lower  end  of,  fracture  of,  475.     Sec 
also  Fractures,  Colics'. 
Raoult-Deslongchamp's  splint,  383 
Rectal    injections    in    intestinal    ob- 
struction, 745 
insufllation,  750,  751 


Rectum,  manual  exploration  of,  754 

myofibroma  of,  obstruction  from, 
964 

walls  of,  intussusception  into,  890 
Reder's  inflatable  bulb,  816 
Reduction,  580 

accidents  of,  585 

bloodless,  582 

b}'  manipvilation,  582 

fracture  during,   585 

open  method,  584   • 
Relapsing     appendicitis.      See     also 

Appendicitis. 
Resection  as  substitute  for  the  am- 
putation, 1090 

for  gtmshot  wounds,  255 

of  bowel,  792,  797.      See  also  En- 
tcrectomy. 

of  joints,  1024.      ^i:c  a.\so  Joints. 

of  rib  in  empyema,  656,  657 

temporary,  of   bony   prominences, 
1026 
Resorcin  as  antiseptic,  197 
Respiration,  artificial,  53 
Retention    of    urine,    puncture    for, 

627 
Retractors,  gauze,  107 1 
Retroglenoid  dislocation,  597 
Retro-uterine  hematocele,  668 
Retrovesical  hematocele,  668 
Reverdin's   resection   of  ankle  joint, 

1046 
Rib  resection  in  empyema,  656,  657 
Ribs,  fractures  of,  treatment,  374 
Rontgen  ray.      See  X-ray. 
Roser's  dilator,  566 

reduction  of  posterior  elbow  dislo- 
cation,  604 
Rotation  method  of  shoulder  reduc- 
tion, 595,  596 
Rubber  drain,  215 
fenestrated,  567 

gloves  in  operations,  172 
Rupture  of  axillary  artery  in  reduc- 
tion of  shoulder,   586 

of  urethra,  302.      See  also  Uretlira. 

of  urinary  bladder,  297-299 
Rydygier's  resection  of  intussuscep- 

tum,  910 


Salicymc  acid  as  antiseptic,  197 
Saline  infusion,  138 

for  gunshot  hemorrhage,  250 

intravenous,  140 

sul)cutaneous,  739 
injections,  intra-intestinal,  in  ])cri- 

tonitis,  691 
solution,  normal,  203 

Szumann's,    138 
Salol  as  anti.sej)tic,  197 
Salpingf)j)eritonitis,  702 
Salt  and  ice  anesthesia,  58 
Salves,     antiseptic,     204.      See     also 

Antiseptic  salves. 
in  wound  dressing,  181 


II28 


INDEX. 


Salzer's    method    of    closing    crural 

canal,  1004 
Sarcoma,  amputation  for,  1065 

and  fractures,  316 

intestinal  obstruction  from,  968 
enterectomy  for,  969 
Satterlee's  bone-cutting  forceps,  1028 
Sayre's  dressing,  375 
Scapula  and  clavicle,  exarticulation 

of,  with  upper  extremity,  1088 
Scar,  intravenous,  histology,  105 
Scarification,  effect  of,  on  peritoneal 
healing,  812 

of  peritoneum,  823,  824 
Schede's  thoracoplasty,  661 
Schimmelbusch-Esmarch  inhaler,  47 
Schimmelbusch's  sterilizing  sponges, 

178 
Schleich's  infiltration  method,  61 

solution,  61 
Scorbutus,  fractures  and,  319 
Screws,  metallic,  535 
Secondary  union,  156 
Senn's  automatic  forceps,  994 

bloodless  amputation  at  hip-joint, 

77 
bone  suture,  534 
chloroform  inhaler,  47 
decalcified  perforated  bone-plate, 

784 
emergency  operating  case,  174 
ether  inhaler,  47 
excision  of  amputation  neuroma, 

1068 
first-aid  package,  238 
hemostatic  forceps,  11 1 
hollow  perforated  splint,  538 
injection  syringe,  626 
.     lateral  pressure  apparatus,  463 
modification  of  Hofmeister's  cat- 
gut sterilization,  109 
of  Jobert's  invagination  suture, 
841 
operation  for  reduction  of  shoulder- 
joint,  1043 
probe,  222 
resection  of  ankle-joint,  1047 

of  elbow-joint  for  tuberculosis, 

1036 
of  intussusceptum ,  909 
of  knee-joint,  1049 
of  shoulder-joint,   1041 
retractor,  306 
sigmoid  catheter,  628 
slide-catch  forceps,  994 
taxis  for  intussusception,  904 
tongue  forceps,  51 
Septicopyemia,  amputation  for,  1062 
Seropurulent  peritonitis,  668 
Serous  suture,  813 
Sharp  spoon,  567 
Shock,  definition,  28 
delayed,  29 
erethic,  35 

treatment,  39 
from  bullet  wounds,  33 


Shock  from  gunshot  wounds,  252 
from  operations,  ^t, 
local,  29 
nature  of,  28 
protracted,  29 
traumatic,  28 
diagnosis,  ^6 
etiology,  29-34 
nationality  and,  30 
nervous  system  and,  30 
operation  for,  38 
pathology,  37 
severity  of,  32 
splanchnic  nerve  and,  32 
symptoms,  34 
temperature  in,  35 
treatment,  38 
Shoulder-joint,  amputation  of,  blood- 
less, 81 
disarticulation  at,  1086 
dislocation  of,  586 
age  and,  587 
anterior,  587 

complications,  592 
examination,  591 
Kocher's  reduction,  596 
lever    method    of    reduction, 

595 
mechanism     of     traumatism, 

587 
pathologic  anatomy,  589 
reduction  in,  594 
rotation  in,  595,  596 
subacromial  flatness  in,  592 
symptoms,  591 
treatment,  594 
downward,  597 
erecta,  588 
etiology,  586 
forward,  587 

from  muscular  contraction,  589 
intracoracoid,   587 
posterior,  597 
preglenoid,  587 

reduction,    rupture    of    axillai-y 
artery  in,  586 
tearing  of  arteries  in,  586 
retroglenoid,  597 
Senn's  operation,  1043 
subacromial,  597 
subclavicular,  587 
subcoracoid,  587 
subglenoid,    597 
varieties,   587 
with  fracture,  598 
drainage  of,  631 
elastic  constriction  at,  81 
resection  of,  1038 
flap  incision,  1040 
history,  1038 
incisions  for,  1039 
Langenbeck's,  1044 
Senn's  incision,  1041 
Sick  in  war,  transportation,  253 
Sigmoidostomy,  765 
Silk,  sterilization  of,  106 


INDEX, 


I  129 


Silkworm  gut,  preparation  of,  113 
Silver  wire  in  pseudarthrosis,  531 
Sims'  sponge  holder,  180 

suture,  126 
Skin,  cocainization  of,  60 

disinfection  of,  for  injection,  617 
tearing  of,  amputation  for,   1061, 
1063 
Skull,  elastic  constriction  of,  81 
fracture  of,  486 
at  base.  4S7 

comminuted  compound,  496 
complete,  487 
diagnosis,  488 
examination,  490 
fissure,  4S7.  48S 
gunshot,  256,  498 
incomplete,  487 
prognosis,  490 
punctured,  487,  498 
symptoms,  488 
treatment,  491 
trephining  in,  492,  493 
vault  of,  487 

with  depression,  treatment,  493 
gunshot  wounds  of,  255 
treatment,  259 
Sloughing  and  ligation,  115 
Smith's  oval  flap  amputation,  1080 

suspension  splints,  378 
Soda  solution  as  sterilizer,  176 
Sodium  chlorid  as  antiseptic,  190 
Soft-rubber  catheter,  French,  633 
South  African  war,  wounds  in,  227 
Spanish  windlass,  89 
Spanish-American       war,       first-aid 

package  in,  235 
Spikes,  metallic,  535 
Spine,  fractures  of,  Verity's  suspen- 
sion splint,  545, 546 
gunshot  wounds  of,  285 
Sphnts  in  first  aid,  243 
Sponges,  aseptic,  177 
Bemay's,  179,  180 
gauze,  180 
sterilization  of,  177 
Spoon, sharp.  567 
Sputa,   intestinal    tuberculosis    and. 

Stab  wounds,  intestinal  fistula  from, 

1005 
Staffordshire  knot,  534 
Staphylococcus  peritonitis.  670 
Starke's  irrigation  apparatus.  525 
Steam  as  hemostatic.  130 

as  sterilizer,  176.  182 
Stenosis,    cicatricial,    intestinal    ob- 
struction from,  868 

congenital,    location  of    stricture, 

939 

occlusion  of  duodcum  by,  927 

treatment.  927 
duodenal  and  pyloric,  diflfercntia- 

tion.  940 
nonmalignant.  of  bowel.  925 
of  colon,  colostomy  for,  765 


Stenosis  of  intestines,  acquired,  929 

cicatricial,  929 
Sterilization  of  bone  ferrules,  541 
of  hypodermic  needles,  614 
preparations,  617 
syringes,  614 
of  room,  etc.,  for  laparotomy,  774 
Sternum,  fractures  of,  treatment,  374 
Stomach  feeding  in  peritonitis,  679 
gunshot  wounds  of,  275 
perforating  ulcer  of,  693 
Stools  in  intestinal  tuberculosis,  938 
Strangulated  hernia,  983.      See  also 

Hernia. 
Strangulation,     abdominal     section 
for,  770 
by  adhesion,  802 
by  appendix,  S04 
by  band,  802 
by  diverticulum,  802 
by  flexion,  802 
intestinal  fistula  from,  1007 
Straw  splint,  376 
Streptococcus  infection,  162 
peritonitis,  670 
pyogenes,  158 
Stricture,    congenital,    of    intestine, 
942 
following  strangulated  hernia,  942 
following  typhoid  ulcer,  943 
malignant,  944 
syphilitic,  943 
traumatic,  of  intestine,  942 
Stripping  hernial  sac,  999 
Stromeycr's  arin  cushion,  376 
Stump  after  Chopart's  amputation, 
1093 
after      Gritti-Stokes'      operation, 

1 104 
care  of,  1077 
dressing  of,  1079 
immobilization  of,  1079 
leg,  ideal,  1 100 
Styj)ticin  as  hemostatic,  136 
Styptics,  133 

for  hemorrhage  on  field,  250 
Subacromial  dislocation,  597 

flatness  in  dislocations,  592^ 
Suliastragaloid  disarticulation,   Mal- 

gaigne's,  1094 
Subclavicular  dislocation,  587 
Subcoracoid  dislocation,  587 
Subcutaneous  medication,  614 
Subglenoid  dislocation,  597 
Sublimate,  intestinal  adhesions  from 

use  of,  870 
Submucosa  of  small  intestine,  813 
Sub])hrenic  abscess,  704 
Sul)scaj)ular  artery,  tearing  of.  in  re- 
duction, ?86 
Sulphate  of  magnesia  injection  after 

evacuation  of  intestines,  7K1 
Sulphurous  acid  as  antiseptic,  197 
Suppurating  joints,  drainage  of,  614, 

629 
Suppuration,  amputation  for,  1063 


II30 


INDEX. 


Suppuration    and  pus-microbes,  re- 
lation, 1 60 
Suprapubic  drainage,  628 
Suspension  splints,  377 
Suture,  absorbable  buried,  206 

bloodless,  212 

bone,  531 
technic,  533 

continued,  212 

"  etagen,"  206 

intestinal,  813 

fistula  from,  10 10 

nerve,  288 

of  arteries,  123 

of  veins,  124 
on  field,  250 

removal  of,  210,  212 

sinus,  126 

tension,  209,  212 

vessel,  for  hemorrhage,  122 

wound,  132 
Suturing,  206 

of  external  incision  after  laparot- 
omy, 284 

perforations,  283 

secondary,  212 

tension,  209 

transverse,  as  prophylaxis  against 
infection  in  fistula,  1020 
Sylvester's  method  of   artificial  res- 
piration, 54 
Syme's   amputation   through   ankle- 
joint  with  excision  of  malleoli, 
1094 

external  urethrotomy  staff,  306 
Synovectomy,  1026 
Synovitis,  tapping  in,  626 
Syphilis,  fractures  and,  318 
Syphilitic  stricture  of  intestine,  943 
Syringe,  exploratory,  618 

hypodermic,  614 
Szumann's  solution,  138,  251 


Tait's  drain,  217 

hemostatic  forceps,  iii 
Tampoji,  Mikulicz,  132 
Tamponade,  aseptic,  131 

on  field,  246 
Tape-measures,  340 
Tarsometatarsal  disarticulation,  Lis- 

franc's,  1092 
Taxis  in  obstruction,  755 

in  strangulated  hernia,  990 
continuance  of,  991 
Teale's  square  flap  operation,  1080 
Tenaculum,  minor  operating,  114 
Tension  suture,  209,  212 
Test  of  Dugas,  592 
Test-line,  Bryant's,  443,  444 
Tetanus,  bacillus  of,  159 

infection,  163 
ThermocaLitery,  88 

improved,  129 
Thiersch's  solution,  202 


Thigh,  amputation  of,  1097,  1105 
site  for,  1066 

fractures  of,  treatment,  545 
Thoracentesis,  622 
Thoracoplasty,  Schede's,  661 
Thrombophlebitis  and  fracture,  566 

in  compound  fractures,  517 
Thrombosis  after  fracture,  396 
Thrombus,  ligation  and,  99,  100 
Thumb,  disarticulation  of,  1083 
Thymol  as  antiseptics,  197 
Tibia,  sections  of,  1098 
Tin  splints,  383 

Tinctura  benzoini  composita  as  an- 
tiseptic, 198 
Tissue  forceps,  994 
Toe,  great,  amputation  of,  1090 

resection    of     metatarsophalan- 
geal joint  of,  1044 
Toes,  amputations  of,  1089 

disarticulation  of  all,  109 1 

elastic  constriction  of,  66 
Torsion,  127 

of  testicle  and  hernia,  differentia- 
tion, 988 
Tracheotomy,  644 

after-treatment,  650 

anesthesia  in,  647 

high,  646,  648 

instruments  for,  647 

low,  649 

median,   645 

rapid,  646 

technic,  647 

tubeless,  650 

tubes,  647,  648 

wound  dressing  after,  650 
Transfusion,  137 

Transplantation  in  enterectomy,  799 
Transverse  suturing  before  operation 

for  artificial  anus,  104 
Treves'  douche  spoon,  1030 
Trocars,  614,  620 
Trochanter,  temporary  resection  of, 

in  hip-joint  resection,  1057 
Trousseau's      double      tracheotomy 

tube,  647 
Truax's  needle-holder,  211 
Tubage  in  intestinal  obstruction,  754 
Tubercular    abscess,    intra-articular 
medication  after,  626 

infection,  peritonitis  and,  671 

peritonitis,  acute,  697 
Tuberculosis,  cecal,  933,  951 

and  of  ascending  colon,  955 

intestinal,  age  and,  931 

of  hernia,  934 

of  hip,  resection  for,  1056 

of  ileum,  951 

of  intestines,  930 

abdominal  section  and  iodoform- 

ization  for,  945 
anatomic   location   of   stricture, 

.  939 
cicatrization  in,  937 
colon  bacillus  in,  941 


INDEX. 


I  MI 


Tuberculosis  of  intestines,  complete 
exclusion  for,  960 
diagnosis,  940 
enterectomy  for,  947 
entero-anastomosis  for,  953 
enteroplasty  for.  946 
etiology,  930 
extension  of  ulcer,  935 
feces  in,  941 
fibrous  form,  934 
frequency,  930 
healing  of  ulcers,  936,  938 
in  children,  932 
induration  in,  939 
ileocecal  abscess  in,  939 
infection  from  blood,  932 
h'mphadenitis  from,  936 
ovarian  tumor  and,  943 
partial  exclusion  for,  953 
patholog}',  932 
peritonitis  from,  936 
resection  of  cecum  for,  949 
seat  of  infection,  932,  935 
stools  in,  938 
surgical  treatment.  944 

safety  of,  951 
swallowing  of  sputa  and,  931 
symptoms,  937 
ulcerative  form,  934 
walls  in,  936 

with  intestinal  obstruction,  954 
with  invagination,  959 
of  knee-joint,  resection  for,  1049 
of  urinary  organs,  955 
peritoneal,  697 

abdominal  section  for,  945 
resection  of  elbow-joint  for,  1036 
synovial,    intra-articular    medica- 
tion after,  626 
resection  for,  1025 
wound  infection  with,  164 
Tubular   and    capillary    drainage    of 
abdominal  cavity,  690 
drainage    of     abdominal    cavity 
688  ^ 

TufFier's  angiotribe,  88 
Tumors,  benign,  intestinal  obstruc-   J 
tion  from,  961  I 

diagnosis,  968 
in  lumen  of  intestine,  764 
intestinal  obstruction  from,  961 
intussusception  and,  891 
malignant,  amputation  for,  1064 
intestinal  fistula  from,  1007 
obstructirm  from,  968 
mortality,  972 
treatment,  972 
of  abdominal  cavity,  619 
of  cecum,  enterectomy  for,  798 
ovarian,  and  tuberculosis.  943 
Turkey,  gunshot  fractures  in.  557 
Turpentine  as  antiseptic.  198 
in  hand  disinfection.  r72 
oil  of,  for  hemorrhage.  133.  13^ 
Tympanites,    intestinal    obstruciirin 
from,  975 


Typhlostomy,  765 

for  obstruction  of  large  intestine 

766  ' 

Typhoid  ulcer,  perforating,  695 

stricture  following,  943 

Ulcer,  gastric,  perforating,  693 
multiple    catarrhal,    of   appendix 

713 
of  duodenum,  perforating,  694 
typhoid,  perforating,  695 
Ulceration,    intestinal    fistula    from, 

1006 
Ulcerative  appendicitis,  713 
Ulna,  dislocation  of,  609 
Umbihcal   hernia,   radical   operation 

for,  998 
Unguentum  Credc,  205 
Upper    extremity,    amputations    of, 
1081 
exarticulation   of,   with   scapula 
and  clavicle,   1088 
Urethra,  male,  633 
microbes  in,  636 
rupture  of,  302 

catheterization,  305 
cause,  302 
classification,  302 
diagnosis,  303 
operations  for,  305,  306 
perineal  section  for,  '306 
recognition  of  urethra  in,  307 
retrograde    catheterization    for, 

308 
suturing  for,  308 
treatment,  305 
surgical  wall  of,  305 
Urethral  canal,  anatomy  of,  634 
curve,    schematic    representation. 
632 
Urinary  bladder.      See  Bladder. 

organs,  tuberculosis  of,  951; 
Urine  in  fat  embolism  with  fracture, 
349 
retention  of,  puncture  for,  627 
Uterus,  operations  on,  steam  in,  130 

Vagina MTis.  suppurative,  and  stran- 
gulated hernia,  differentiation ,  988 

Va.selin.  sterilized,  as  catheter  lubri- 
cant, 639 

Vasotribe,  88 

Veins,  percutaneous  temporary  liga- 
tion of.  87 
suture  of,  124 

Velpeau's  bone-cutting  forceps.  1028 

Ventrofixation     after     volvulus     re- 
moval.  864 

Verity's  suspension  splint.  545.  546 

Vertebra-,    fractures    of.    treatlnent, 
374 

Vessel  suture  ff>r  hemorrhage.  122 

Vessels,  tearing  of,  amputations  f(jr, 
1 06 1 


II32 


INDEX. 


Vicious  union,  410 
Visceral  peritonitis,  664 
Volkmann's   dorsal   splint  for  ankle 
excision,  1048 

dropping  tube,  527 

four-prong  retractor,  306 

method  of  uniting  fractures,  40S 

pelvic  support,  463 

resection         of        intussusceptum 
through  rectum,  912 

sliding  foot-board,  387 

spoon, 1029 
Volvulus,  850 

abdominal  taxis  for,  857 

after  strangulated  hernia,  852 

after  typhoid  ulcer,  853 

colostomy  after,  reduction,  864 

diagnosis,  855 

emptying  bowel  in,  860 

enterectomy  in,    86 5 

enterostomy  for,  864 

exciting  causes,  854 

frequency,  850 

from  elongation,  852 

from   intestinal   adhesions   to   ab- 
dominal wall,  853 

incision  for,  859 

insufflation  for,  858 

intestinal  anastomosis  in,  861 

laparotomy  for,  mortality,  858 

length  of  intestinal  canal  and,  852 

of  sigmoid  flexure,  855 

predisposing  causes,  850 

prognosis,  856 

reposition,  859 

shortening  mesenterj^  after,  862 

spontaneous  reposition,  854 

symptoms,  849,  855 

treatment,  856 

tympanites  in,  855 

ventrofixation  after  removal,  864 


Walther's  disarticulation  at  wrist- 
joint,  1081,  1085 

Water,  boiling,  as  sterilizer,  176 
hot,  for  hemorrhage,  129 

on  field,  250 
microbes  in,  200 
sterilizing  of,  201 

Watson's  suspension  splint  for  knee- 
joint,  1056 

Waxham's  mouth-gag,  641 

Web  catheter,  prostatic,  635 

Wein's  first  aid,  234 

Wells'  hemostatic  forceps,  112 

Wheelhouse's  beaked  straight  staff, 
306 

Windlass,  Spanish,  89 

Windler's  saw,  1070 

Wire  splints,  383 

Wound  suture,  132 

Wounded,  transportation  of,  253 

Wounds,  142 

before  aseptic  surgery,  142 
bullet,  shock  from,  33 


I   Wounds,  compression  and,  214 
'        contused,  148 
drainage  of,  214 
dressing  material  for,  180 
granulating    surfaces    of,    appear- 
ance, 155 
gunshot,  218 

amputation  and,  254 

antiseptic  dressings,  237 

craniectomy  for,  254 

diagnosis,  220 

first-aid  treatment,  233,  234 

from  small-caliber  bullet,  241 

gangrene  from,  559 

hemorrhage  from,  arrest  of,  244 
autotransfusion  in,  251 
digital  compression  for,  246 
elastic  constriction  for,  244 
elevation  for,  245 
flexion  for,  246 
forcipressure  for,  249 
hot  water  for,  250 
internal,  247 
lateral  ligation  for,  250 
ligation  for,  249 
saline  infusion  after,  250 
styptics  for,  250 
tamponade  for,  246 
vein  suture  for,  250 

immobilization  after,  253 

in  South  Africa,  227 

infection  of,  229 

intestinal  fistula  from,  1005 

laparotomy  for,  254 

of  abdomen,  273.      See  also  Ab- 
domen. 

of  arteries,  290 

of  chest,  261.     See  also  Chest. 

of  heart,  262 

of  hollow  viscera,  220 

of  joints,  treatment,  1024 

of  kidneys.   291.    See  also  Kid- 
ney. 

of  neck,  259 

of  nerves,  288 

of  skull,  255 
treatment,  259 

of  spine,   285 

of  stomach,  275 

of  urinary  bladder,  297 

primar}^  dressing  of,  252 

probing,  221,  222 

prognosis,  225 

resection  for,  255 

search  for  perforation,  282 

shock  from,  252 

treatment,  229 

'K-ray  in,  223 
incised,  145 
infection  of,  157 

nonsuppurative,  162 

prevention,  164,  1S5 

streptococcic,    162 

suppurative,  157 

susceptibility  to,  161 

tetanic,  163 


INDEX. 


I  I 


Wounds,  infection  of,  trained  nurse 
and, 65 

tuberculous,  164 
intestinal,  healing  of,  8 16 
lacerated,   147 
micro-organisms  in,  157 
of  urinary  bladder,  297 

treatment,  300 
poisoned,  152 
profusely    secreting,    dressing    of, 

1 84 
punctured,  150 
repair  of,  153 

by  primary  intention,  154 

by  secondarv- intention,  156 

surgeon's  duty,  154 
salves  in  dressing  of,  180 
splints  for,  183 
stab,  150 
superficial-,  dressing  of,  181 


Wounds,  .suturing,  206 

treatment,  mechanical,  205 
position,  206 
Wrist-joint,  amputation  above,  1069 

amputation  at,  10S5 

disarticulation  at,  1085 
Walther's,  108 1 

resection  of,  1034 
Wyeth's    bloodless    amputation     at 

hip-joint,  75,  76 


X-R.ws  in  fractures,  343 
in  military  surgery,  223 


Zinc  chlorid  as  antiseptic,  190 

solution,  203 
Zoege-Mantcuffel's    classification    of 
intestinal  obstruction,  847 


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Chapin  on  Insanity. 

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Church  and  Peterson's  Nervous  and  Mental  Diseases. 

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Hart's  Diet  in  Sickness  arid  in  Health. 

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Haynes*  Anatomy. 

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Hyde  and  Montgomery  on   Syphilis  and  the  Venereal 

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^e  International  Text- Book  of  Surgery,     in  Two  volumes. 

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Jackson's  Diseases  qf  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
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Keatin^'s  Life  Insurance. 

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Keen  on  the  Surgery  qf  Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm. 
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Keen's    Operation    Blank.       second  Edition.  Revised  Form. 

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Kyle  on  the  Nose  and  Throat,     second  Edition. 

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Levy,  Klemperer,  and  Eshner's  Clinical  Bacteriology. 

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Lockwood's  Practice  qf  Medicine. 

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Long's  Syllabus  cf  Gynecology. 

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Macdonald's  Surgical  Diagnosis  and  Treatment. 

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McFarland's  Pathogenic  Bacteria.   '""^^^lytZ'^'^^lt^ 

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Meigs  on  Feeding  in  Infancy. 

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Ogden  on  the  Urine. 

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Penrose's  Diseases  qf  Women.    Third  Edition,  Revised. 

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OF    IV.  B.  SAUNDERS   er'    CO. 


Pryor— Pelvic  Inflammations. 

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Pye*s  Bandaging. 

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Raymond's  Physiology. 

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ami  enlarge  1. 

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oil  Uri.ne  E.KAMI  nation.  By  Lawrence  Wolff,  M.  D.  'Ihird  edition,  enlarged 
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present  out  of  )>rint. 

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15.  Essentials  of    Dueases    of   Children.      By   Wii.i.iam    M.    I'owei.i  ,   M.  D.     Second 

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Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

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Atlas  and  Epitome  of  Operative  Surg»ery. 

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Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

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man Edition.  Edited  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gyne- 
cologist to  the  Methodist  Episcopal  and  the  Philadelphia  Hospitals  ; 
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plates,  65  text-illustrations',  and  308  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  the  Nervous  System  and  its 
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By  Professor  Dr.  Chr.  Jakoh,  of  Erlangen.  From  the  Second  Re- 
vised German  Edition.  Edited  by  Edward  D.  Fisher,  M.  D.,  Pro- 
fessor of  Diseases  of  the  Nervous  System,  University  and  Bellevue 
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Atlas    and    Epitome    of    Labor   and   Operative    Ob- 
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Edition.  Edited  by  J.  Clifton  Edgar,  M.  D.  ,  Professor  of  Obstetrics 
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Atlas    and    Epitome    of    Obstetrical    Diagnosis    and 
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Edition.  Edited  by  J.  Clifton  Edoar,  M.  D.,  Professor  of  Obstetrics 
and  Clinical  Midwifery,  Cornell  University  Medical  S(  hool.  With  122 
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German  I'.dition.  VA\wA  \)y  (\.  \\.  dk  Scmwkinu/,  M.  D.,  I'rofcssor 
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ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Boliin,  Davidofif,  and  Huber— A  Text- 
Book  of  Histology 

Clarkson — A  Text-Book  of  Histology, 

Haynes — A  Manual  of  Anatomy,    .    . 

Heisler — A  Text- Book  of  Embryology, 

Leroy — Essentials  of  Histology,  .    .    . 

Nancrede — Essentials  of  Anatomy,  .   . 

Nancrede — Essentials  of  Anatomy  and 
Manual  of  Practical  Dissection 


BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology, 15 

Crookshank — A  Text-Book  of  Bacteriol- 
ogy   S 

Protbingliani — Laboratory  Guide,  ....  6 
Levy  and  Klemperer's  Clinical  Bacteri- 
ology   9 

Mallory  and  Wright— Pathological  Tech- 
nique   g 

McFarland — Pathogenic  Bacteria 9 

CHARTS,  DIET-LISTS,  ETC. 

Griffith — Infant's  Weight  Chart, 7 

Hart — Diet  in  Sickness  and  in  Health,  .    .  7 

Keen — Operation  Blank 8 

Laine — Temperature  Chart 9 

Meigs — Feeding  in  Early  Infancy 10 

Starr— Diets  for  Infants  and  Children,  .    .  12 

Thomas— Diet-Lists 13 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Physics,  15 

Wolff — Essentials  of  Medical  Chemistry,  .  15 

CHILDREN. 
An  American  Text-Book  of  Diseases  of 

Children i 

Griffith— Care  of  the  Baby, 7 

Griffith— Infant's  Weight  Chart 7 

Meigs — Feeding  in  Early  Infancy 10 

Powell^Essentials  of  Diseases  of  Children,  15 

Starr— Diets  for  Infants  and  Children,  .    .  12 

DIAGNOSIS. 

Cohen  and  Eshner— Essentials  of  Diag- 
nosis   15 

Corwin — Physical  Diagnosis, 5 

Macdonald — Surgical  Diagnosis  and  Treat- 
ment,     9 

Vierordt — Medical  Diagnosis 14 

DICTIONARIES. 

The  American  Illustrated  Medical  Dic- 
tionary   3 

The  American  Pocket  Medical  Dictionary,  3 

Morten — Nurses'  Dictionary, 10 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases  of 

the  Eye,  Ear,  Nose,  and  Throat i 

De  Schweinitz — Diseases  of  the  Eye,    .    .     6 
Friedrich  and  Curtis — Rhinology,  Laryn- 
gology, and  Otology,  and  their  Signifi- 
cance in  General  Medicine, 6 

Gleason — Essentials  of  Diseases  of  the  Ear,    15 
Griinwald  and  Grayson — Atlas  of  Dis- 
eases of  the  Larynx, 16 

Haab  and  De  Schweinitz— Atlas  of  Exter- 
nal Diseases  of  the  Eye 16 

Jackson — Manual  of  Diseases  of  the  Eye,     8 
Jackson  and  Gleason — Essentials  of  Dis- 
eases of  the  Eye,  Nose,  and  Throat,  .    .    15 
Kyle — Diseases  of  the  Nose  and  Throat,  .      9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito-Uri- 

naryand  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 

Venereal  Diseases, 8 

Martin—Essentials     of     Minor     Surgery, 

Bandaging,  and  Venereal  Diseases,  .  .  .  15 
Mracek  and  Bangs — Atlas  of  Syphilis  and 

the  Venereal  Diseases, 16 

Saundby — Renal  and  Urinary  Diseases,  .  .  11 
Senn — Genito-Urinary  Tuberculosis,  ...  12 
Vecki — Sexual  Impotence, 14 


GYNECOLOGY. 

American  Text-Book  of  Gynecology 
Cragin — Essentials  of  Gynecology, 
Garrigues — Diseases  of  Women, 
Long — Syllabus  of  Gynecology,  . 
Penrose — Diseasesof  Women, .  . 
Pryor — ^Pelvic  Inflammations,  .  . 
Schaefifer  and  Norris — Atlas  of  Gynecol- 
ogy  


17 


MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied  Ther- 
apeutics   I 

Butler— Text-Book   of    Materia    Medica, 

Therapeutics,  and  Pharmacology,   ...  4 

Cerna — Notes  on  the  Newer  Remedies,  .    .  4 
Morris — Essentials  of  Materia  Medica  and 

Therapeutics 15 

Saunders'  Pocket  Medical  Formulary,  .    .  11 

Sayre — Essentials  of  Pharmacy, 15 

Stevens — Manual  of  Therapeutics,  ....  13 
Stoney — Materia  Medica  for  Nurses,  ...  13 
Thornton — Dose-Book  and  Manual  of  Pre- 
scription-Writing,      13 


MEDICAL  PUBLICATIONS  OF  IK  B.  SAUNDERS  &-  CO. 


19 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — Medical  Jurisprudence  and 
Toxicology c; 

Golebiewski  and  Bailey— Atlas  of  Dis- 
eases Caused  by  Accidents 17 

Hoflnann  and  Peterson— Atlas  of  Legal 
Medicine 16 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Chapin — Compendium  of  Insanity,     ...      5 
Churcli  and  Peterson — Nervous  and  Men- 
tal Diseases 5 

Shaw — Essentials  of  Nervous  Diseases  and 
Insanity 15 

NURSING. 

DaviS^Obstetric  and  Gynecologic  Nursing,  6 

Griffith— The  Care  of  the  Baby 7 

Hart — Diet  in  Sickness  and  in  Health,    .    .  7 

Meigs — Feeding  in  Early  Infancy 10 

Morten — Nurses'  Dictionary 10 

Stoney — Materia  Medica  for  Nurses,      .    .  13 

Stoney — Practical  Points  in  Nursing,  ...  13 

Stoney— Surgical  Technic  for  Nurses,    .    .  13 

Watson^ Handbook  for  Nurses,     ....  14 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,    .  2 

'Ashton — l-^ssentials  of  Obstetrics 15 

Boislini^re — Obstetric  Accidents 4 

Dorland — Manual  of  Obstetrics 0 

Hirst — Text-Book  of  Obstetrics,     ....  7 

Norris — Syllabus  of  Obstetrics 10 

Schaeffer  and  Edgar — Atlas  of  Obstetri- 
cal Diagnosis  and  Treatment 17 

PATHOLOGY. 

An  American  Text-Book  of  Pathology,    .     2 
Diirck  and  Hektoen — Atlas  of  Pathologic 

Histology 16 

Ealteyer — Essentials  of  Pathology,    ...    15 
Mallory  and  Wright — Pathological  Tech- 

ni(|ue 9 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors, 12 

Stengel — Text-Book  of  Pathology,    ...    12 
Warren — Surgical  Pathology  and  Thera- 
peutics  14 

PHYSIOLOGY. 

An  American  Text-Book  of  Physiology,  2 

-I  .s-cniials  of   l'liy-.i(>logy 15 

Raymond — .Manual  of  Physiology,     ...  11 

Stewart     .Manual  of  Ph/siology 13 

PRACTICE  OF  MEDICINE. 

An  American  Year-Book  of  .Medicine  and 
Surgery 3 

Anders — Text-liook  of  the  Practice  of 
.M'di'inc 4 

Eichborst — Practice  of  Medicine '' 

Lockwood — Manual  of  the  Practice  of 
.M'd,<  inc 9 

Morris  -Essirntials  of  Practice  of  Medi- 
cine.  ...  «.=; 

Salinger  and  Kalteyer  -.Morl.-rn  Medi- 
cine  " 

Stevenf- Manual  of  Practice  of  Medicine,    13 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases 2 

Hyde  and  Montgomery— Syphilis  and  the 
Venereal  Disea.ses,  .    .    .  ' 8 

Martin —  Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,     .    .    15 

Mracek  and  Stelwagon — Atlas  of  Diseases 
of  the  Skin, 16 

Stelwagon — Essentials  of  Diseases  of  the 
Skin 15 

SURGERY. 

An  American  Text-Book  nf  Surgery,  .  .  2 
An  American  Year-Book  of  Medicine  and 

Si"'g^''y 3 

Beck — Fractures 4 

Beck — Manual  of  Surgical  Asepsis,    ...  4 

Da  Costa — Manual  of  Surgery 5 

International  Text-Book  of  Surgery,  .    .  8 

Keen — Operation  Blank 8 

Keen — The   Surgical    Complications   and 

Setjuels  of  Typhoid  Fever 8 

Macdonald — Surgical  Diagnosis  and^Treat- 

ment 9 

Martin —  Es.sentials    of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,      .    .  15 

Martin—  h'ssentials  of  Surgery 15 

Moore — Orthopedic  Surgery 10 

Nancrede — Principles  of  Surgery 10 

Pye — Bandaging  and  .Surgical  Dressing,     .  ii 

Scudder — Treatment  of  Fractures,     ...  12 

Senn — Genito-Urinary  Tuberculosis,  ...  12 

Senn — Practical  Surgery 12 

Senn — Syllabus  of  .Surgery 12 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Warren — Surgical  Pathology  and  Thera- 
peutics   14 

Zuckerkandl  and    Da    Costa— Atlas    of 

Operative  .Suigery lb 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  Examination  of  the  Urine,  10 
Saundby — Renal  and  Urinary  Diseases,  .  11 
Wolff— I'^ssentials  of  Examination  of  Urine,    15 

MISCELLANEOUS. 

Abbott  llvgienc  of  Tr.iiismissible  Dis- 
eases, .    .' 3 

Bastin— I.alxjralorv  Exercises  in  Botany,  .  4 
Golebiewski  knd  Bailey— Atlas  of  Dis- 

easis  Caiiscrl   by  Accidents, 17 

Gould  and  Pyle— Anomalies  and  Curiosi- 

tic-s  of   Medicine 7 

Grafstrom— Massage 7 

Keating  -llow  to  Examine  for  Life  Insur- 
ance  " 

Pyle  -  A  Manual  of  Pcrnonnl  HyRicne,  11 
Saunders'  Medical  Iland-Allases.  .  16. 17 
Saunders'  I'nckct  Medical  I'oimulnry,  .11 
Saunders'  (Question  ('umpends,  .  .  .  14. '5 
Stewart    and    Lawreno*— Essential.^   of 

Medical    I'.l.-clri.ity IS 

Thornton      Dose  Book    and    Manual    of 

Pri>,' lipiion-W'iitiin.; '3 

Van  Valzah  and  Nisbet  Diseavs  <<(  ilie 
.Slomucli,  '3 


NOTHNAGEL'S  ENCYCLOPEDIA 

OF 

SPECIAL  PATHOLOGY  AND  THERAPEUTICS 


IT  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal 
Medicine  ;  and  of  all  the  German  works  on  this  subject,  Nothnagel's  '*  Ency- 
clopedia of  Special  Pathology  and  Therapeutics"  is  conceded  by  scholars  to 
be  without  question  the  best  System  of  Medicine  in  existence.  So  necessary 
is  this  book  in  the  study  of  Internal  Medicine  that  it  comes  largely  to  this  country 
in  the  original  German.  In  view  of  these  facts,  Messrs.  W.  B.  Saunders  &  Com- 
pany have  arranged  with  the  publishers  to  issue  at  once  an  authorized  edition 
of  this  great  encyclopedia  of  medicine  in  English. 

For  the  present  a  set  of  some  ten  or  twelve  volumes,  representing  the  most 
practical  part  of  this  encyclopedia,  and  selected  by  a  competent  editor  with  espe- 
cial thought  of  the  needs  of  the  practical  physician,  will  be  published.  These 
volumes  will  contain  the  real  essence  of  the  entire  work,  and  the  purchaser  will 
therefore  obtain  at  less  than  half  the  cost  the  cream  of  the  original.  Later 
the  special  and  more  strictly  scientific  volumes  will  be  offered  from  time  to. 
time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  the  original,  it  will  represent  the 
very  latest  views  of  the  leading  American  specialists  in  the  various  departments 
of  Internal  Medicine.  The  whole  System  will  be  under  the  editorial  super- 
vision of  a  clinician  of  recognized  authority,  who  will  select  the  subjects  for  the 
American  edition,  and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  of  its  publicatfon  by  the  American  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be 
given  the  opportunity  of  subscribing  for  the  entire  System  at  one  time ;  but  any 
single  volume  or  any  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  many  advantages  which  will  be  appreciated  by  those 
who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  publishers  feel  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 


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